
Cilass. 
Book. 



COPYRIGHT DEPOSIT 



BEAIISr SURG-EEY 



^ 



BY 



M. ALLEN STARR, M.D., Ph.D. 

PEOFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM, COLLEGE OF PHYSICIANS 
AND SURGEONS, MEDICAL DEPARTMENT OF COLUMBIA COLLEGE, NEW YORK; 
PRESIDENT OF THE NEW YORK NEUROLOGICAL SOCIETY; CON- 
SULTING NEUROLOGIST TO THE PRESBYTERIAN, 
ORTHOPEDIC AND BABIES HOSPITALS 



WITH FIFTY-NINE ILLUSTRATIONS 




NEW YORK 
WILLIAM WOOD & COMPANY 

1893 



-Yv> 



Copyright, 1893, by 
WILLIAM WOOD & COMPANY 



PREFACE. 



Brain surgery is at present a subject both novel 
and interesting. It is within the past five years only 
that operations for the rehef of epilepsy and of im- 
becility, for the removal of clots from the brain, for 
the opening of abscesses, for the excision of tumors, 
and for the relief of intracranial pressure have been 
generally attempted. These operations are the prac- 
tical outcome of the acceptance of the facts of locali- 
zation of brain function established by the combined 
labor of physiologists, clinical observers, and pathol- 
ogists. 

Brain surgery has as its essential basis the accurate 
diagnosis of cerebral lesions, which was impossible 
until the localization of cerebral functions had been 
determined. And this diagnosis must be made by the 
physician before the surgeon is called in to remove the 
disease. 

It is the object of this book to state clearly those 
facts regarding the essential features of brain disease 
which will enable the reader to determine in any case- 
both the nature and the situation of the pathological 
process in progress, to settle the question whether the 
disease can be removed b}" surgical interference, and 



IV 



PREFACE. 



to estimate the safety and probability of success by 
operation. 

The facts have been reached by a careful study of 
the literature of the subject and by a considerable 
personal experience. The number of articles written 
upon brain surgery, the number of cases recorded and 
of operations reported in this country and in Europe 
during the past ten years is enormous. This litera- 
ture is accessible to those only who have a large medi- 
cal library at their command and who have the time 
for literary research. I have undertaken to bring to- 
gether and to sift the scattered facts, to arrange them 
in an orderly sequence, and to deduce such conclusions 
from their analysis as seem warranted by critical 
study. While in no way disregarding the work of 
foreign observers, I have endeavored to utilize Ameri- 
can observations and to cite American cases in prefer- 
ence to others. And this has in no way hampered 
me, for it is to the industry and genius of American 
surgeons that much of the great advance in this de- 
partment of surgery is due. 

To this collection of facts I am able to contribute a 
considerable number of cases of cerebral disease, oper- 
ated upon under my direction. My own experience in 
the clinical study of brain diseases and my observation 
of the method and results of operations performed by 
different surgeons have enabled me to estimate the 
statements of other writers with some degree of criti- 
cal judgment, and to arrive at certain convictions of 
my own. 



PREFACE. V 

I have to express my deep obligation to Dr. McBur- 
ne}' for placing at my entire disposal the large number 
of cases in which he has operated for me, and for a 
revision of the chapter upon the operation of trephin- 
ing ; and also my thanks to Drs. Weir, Hartley, Poore, 
and Briddon for permission to cite the cases which 
I have seen with them. I am indebted to Dr. Van 
Gieson for the very careful investigation of patho- 
logical material placed in his hands and for the draw- 
ings which illustrate his descriptions. 

It is my hope that this work may aid the physician 
to diagnosticate brain diseases with more accuracy, 
and to select such cases as are properly open to sur- 
gical treatment by trephining; and also that it may 
enable the surgeon to perform his delicate task with 
more precision and with a fuller knowledge of those 
principles of local diagnosis v/hich should form his 
constant guide. 

M. Allen Starr. 

No. 22 West 48th Street, New York, 
March 27th, 1893. 



CONTENTS. 



CHAPTER I. 
The Diagnosis of Cerebral Disease. 

PAGE 

Diagnosis is Preliminary to Operation and must be Made by the 
Physician before Surgical Treatment is Attempted. The 
Diagnosis of the Nature of the Cerebral Lesion. The Diag- 
nosis of the Situation of the Cerebral Lesion. The Facts of 
Localization Essential to Diagnosis. Cranio- Cerebral To- 
pography, . . . 1 

CHAPTER II. 

Trephining for Epilepsy. 

The Varieties of Epilepsy. Jacksonian Epilepsy. The Motor 
Form of Attack. The Sensory Form of Attack. The Aphasic 
Form of Attack. The Psychical Form of Attack. Traumatic 
Epilepsy. The Operation for Epilepsy. Records of Cases 
of Epilepsy operated upon, Personal and Selected. The 
Pathology of Jacksonian and Traumatic Epilepsy. The Re- 
sults of Trephining for Epilepsy. Conclusion, . . .19 

CHAPTER III. 
Trephining for Imbecility Due to Microcephalus. 

Clinical Types of Microcephalic Children : (1) Paralytic Cases ; 
(2) Imbeciles ; (3) Cases of Sensory Defect. The Occur- 
rence of Epilepsy in these Children. The Pathology of these 
Clinical Types. The Operation of Craniotomy and its Re- 
sults. Table of Cases. Report of Personal Cases. Conclu- 
sions, ........... 114 



Vlll CONTENTS. 

CHAPTER IV. 
Trephining for Cerebral Hemorrhage. 

PAGE 

Records of Cases of Clots Removed from tlie Brain. Report of 
Personal and Selected Cases. The Symptoms of Traumatic 
Cerebral Hemorrhage. The Differential Diagnosis Between 
Intra-Dural and Extra-Dural Hemorrhage. Operations for 
Non- Traumatic Hemorrhage, 157 

CHAPTER V. 
Trephining for Abscess of the Brain. 

The Surgical Treatment of Brain Abscess. The Varieties of 
Brain Abscess. (1) Traumatic Abscesses. Surgical Indica- 
tions for Trephining, General and Local. Report of Cases. 
(2) Abscesses Secondary to Ear Disease. Symptoms. Dif- 
ferential Diagnosis between Abscess, Meningitis, and Sinus 
Thrombosis. The Situation for Trephining after Ear Dis- 
ease. Illustrative Cases. Conclusions 179 

CHAPTER VI. 
Trephining for Tumor of the Brain. 

The Frequency and Varieties of Tumors in the Brain. Analysis 
of Six Hundred Tumors. Tumors in Children Contrasted 
with Tumors in Adults. The Diagnosis of the Nature of 
the Tumor. The Diagnosis of the Situation of the Tumor. 
The Percentage of Brain Tumors Open to Operation. The 
Results of Operation for Brain Tumors. Analysis of Ninety- 
seven Cases. I. Cerebral Tumors. Selected American 
Cases. Personal Case. Tumor of Frontal Lobes. 11. Cere- 
bellar Tumors. Diagnosis. Difficulties of Operation. Three 
Personal Cases. Table of all Brain Tumors Operated upon. 
Conclusions, .......... 200 

CHAPTER VII. 

Trephining for Hydrocephalus and for the Relief of 
Intracranial Pressure. 

Hydrocephalus. Tapping the Lateral Ventricles. Keen's Cases. 
Robson's Cases. Broca's Cases. General Conclusions. 
Methods of Operation. Trephining to Relieve Intracranial 
Pressure, ......... 256 



CONTENTS. IX 

CHAPTER VIII. 
Trephining for Insanity. 

PAGE 

Traumatic Insanity in Relation to Insanity in General. Report 
of Cases Operated Upon. Trephining in General Paresis. 
Uselessness of the Operation, 267 

CHAPTER IX. 
Trephining for Headache, and Other Conditions, . 273 

CHAPTER X. 

The Operation of Trephining. 

The Necessity of Antiseptic Precautions. The Preparation of 
the Patient. The Choice of an Anaesthetic. Marking the 
Scalp. The Incision in the Scalp. Methods of Opening 
the Skull. The Treatment of Hemorrhage. Opening of the 
Dura. The Exploration of the Brain. The Closure of the 
Wound 275 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Diagram of the Functional Areas of the Right Hemisphere, 4 

2. Diagram of the Functional Areas of the Left Hemisphere, . 5 

3. Diagram of the Median Surface of the Right Hemisphere, . 7 

4. The Projection Tracts within the Brain, .... 9 

5. The Association Tracts within the Brain, . . . .10 

6. Photograph of the Head and Brain (Fraser) , ... 12 

7. Photograph of a Cast of the Head, 13 

8. Diagram of the Cranial Measurements to Locate the Fissures, 14 

9. Diagram of the Relations of the Skall and the Brain (Reid) , 15 

10. Diagram to Show the Relation of the Skull and the Func- 

tional Areas of the Right Hemisphere, . . . .16 

11. Diagram to Show the Relation of the Skull and the Func- 

tional Areas of the Left Hemisphere, . . . .17 

12. Diagram to Show the Opening in the Skull in Case I. , . 30 

13. Diagram to Show the Opening in the Skull in Case II., . 32 

14. Diagram to Show the Opening in the Skull in Case III. , . 36 

15. Diagram to Show the Opening in the Skull in Case IV. , . 37 

16. Diagram to Show the Opening in the Skull in Case V. , .39 

17. Diagram to Show the Opening in the Skull in Case VI. , . 42 

18. Diagram to Show the Opening in the Skull in Case VII. , . 43 

19. Diagram to Show the Opening in the Skull in Case VIII. , . 45 

20. Diagram to Show the Opening in the Skull in Case IX. , . 47 

21. Diagram to Show the Opening in the Skull in Case X., .48 

22. Diagram to Show the Opening in the Skull in Case XL, . 50 

23. Diagram to Show the Opening in the Skull in Case XII., . 53 

24. Diagram to Show the Opening in the Skull in Case XIII. , . 54 

25. Section through Pia and Cortex Showing Meningitis, . . 71 

26. Section Showing Spiculum of Bone in the Brain in Case III. , 84 

27. Degeneration of Brain Cells in Epilepsy, . . . .87 

28. Degeneration of Brain Cells in Epilepsy, . . . .89 

29. Degeneration of Brain Cells in Epilepsy, . . . .90 

30. Changes in the Neuroglia in Epilepsy, . . . . .98 

31. Changes in the Neuroglia in Epilepsy, ..... 99 

32. Neuroglia Cells Undergoing Changes in Epilepsy, . . 100 



Xll 



LIST OF ILLUSTRATIONS. 



FIG. 

33. Adhesion of Scalp and Cortex in Case II. , . 

34. Section Sliowing Changes in Membranes and Brain in Case 

II., 

35. Clianges in the Cortex in Case II. , 

36. The Capillaries and the Neuroglia in Case II. , 

37. The Neuroglia in Case II. , . 

38. Porencephalic Brain (Shattenberg) , 

39. Porencephalic Brain (Ferraro) , . . . 

40. Porencephalic Brain (Ferraro) , . . . 

41. Hemiatrophy of the Brain, Superior Surface, 

42. Hemiatropliy of the Brain, Inferior Surface, 

43. Hydrocephalus (Delafield and Prudden) , 

44. Diagram to Show the Opening in the Skull in Case XIV. , . 

45. Diagram to Show the Opening in the Skull in Case XV. , . 

46. Diagram to Show the Opening in the Skull in Case XVI. , . 

47. Diagram to Show the Opening in the Skull in Case XVII. , . 

48. Diagram to Show the Opening in the Skull in Case XVIII. , . 

49. Diagram to Show the Situation of the Clot in Case XVIII. , . 

50. Diagram to Show Relation of Skull and Functional Areas of 

the Left Hemisphere, . . . . . . , , 

51. Diagram to Show the Opening in the Skull in Case XIX. , . 

52. Diagram to Show the Opening in the Skull in Case XX. , 

53. Photograph of the Brain Abscess in Case XX. , . . . 

54. Lateral Aspect of the Skull with Trephine Openings (Bal- 

lance), 

55. The Cerebral Axis (Allan Thompson), 

56. Photograph of the Skull and Brain (Fraser) , . . . 

57. Diagram to Show the Opening in the Skull in Case XXI. , . 

58. Photograph of a Tumor Removed from the Brain in Case 

XXI 

59. Hydrocephalus (Delafield and Prudden) , .... 



103 

105 
107 
109 
110 
125 
126 
127 
130 
131 
132 
142 
145 
147 
149 
164 
165 

170 
175 
186 

187 

193 
210 
211 
234 

235 

265 



BRAIN SURGERY, 



CHAPTER I. 

THE DIAGNOSIS OF CEREBRAL DISEASE. 

Diagnosis is Preliminary to Operation and must be Made by the Phy- 
sician before Surgical Treatment is Attempted. The Diagnosis 
of the Nature of the Cerebral Lesion. The Diagnosis of the Sit- 
uation of the Cerebral Lesion. The Facts of Localization Essen- 
tial to Diagnosis. Cranio- Cerebral Topography. 

There are two essential preliminaries to any opera- 
tion upon the brain. The first is the diagnosis of the 
nature of disease which is present, and the second is 
the diagnosis of its situation. Both are purely medi- 
cal questions, and until they are decided the surgeon 
cannot be asked to operate. 

The diagnosis of the nature of disease in the brain 
is usually one of no great difficulty. The general 
cerebral symptoms characteristic of meningitis, either 
of the dura mater or of the pia mater, of hydrocepha- 
lus, of cerebral hemorrhage, of cerebral softening from 
embolism or thrombosis, of cerebral abscess, of cere- 
bral tumor, and of sclerosis of the brain are in the 
majority of cases quite evident. The differential 
diagnosis between these conditions is elaborately dis- 



2 BRAIN SURGERY. 

cussed in every text-book on practice and on neurology. 
A careful study of the various symptoms, of the order 
and manner of their development, and of the general 
history of the case will usually lead with little diffi- 
culty to a diagnosis of the nature of the lesion present. 

It is not my purpose to enter upon the discussion of 
the diagnosis of cerebral disease in general. In the 
course of the following chapters and in the recital of 
certain cases the essential facts will be carefully con- 
sidered. But it should not be forgotten that surgical 
interference is by no means warranted in any case un- 
less the nature of the disease is well determined. 

The second essential preliminary to operation is a 
knowledge of those facts regarding the localization of 
brain functions, so far as they are at present deter- 
mined, which may lead to a correct diagnosis of the 
situation of the disease. These facts may be stated 
briefly. 

The Fads of Localization. 

There are certain areas upon the cortex of the brain, 
not necessarily co-extensive with either lobes or con- 
volutions, whose functions are accurately known. 

These areas are : (1) the sensori-motor area. (2) The 
speech areas. (3) The visual area. {-^) The auditory 
area. (5) The area of sensations of smell and of taste. 

(1) The sensori-motor area (Figs. 1 and 2) includes 
the cortex of the anterior and posterior central convo- 
lutions which border the fissure of Eolando and the 
adjacent cortex in front and behind these convolutions. 



- THE DIAGNOSIS OF CEREBRAL DISEASE. 3 

Each hemisphere controls movement on the opposite 
side of the body, but as the right hand is more gener- 
ally used and is better trained than the left, this area 
is larger on the left hemisphere than on the right. 

The cortex of the posterior part of the second fron- 
tal convolution controls the movements of the eyes 
and head. Impulses starting from this area produce 
conjugate movement of these parts toward the 
opposite side. The eye district is below, the head dis- 
trict above. 

The lower third of the anterior and posterior cen- 
tral convolutions governs the movements of the face, 
tongue, larynx, and pharynx. The eyebrows and 
cheeks are controlled by the upper and forward part 
of this area; the tongue and larynx by the lower 
and forward part ; the mouth, pharynx, and platysma 
by the hinder part. 

The middle third of the anterior and posterior cen- 
tral convolutions governs the movements of the upper 
extremity ; the shoulder motions being controlled in 
the anterior and upper part of this area, the elbow 
motions in its middle part, and the hand and finger 
motions in its posterior and lower part. 

The upper third of the anterior and posterior cen- 
tral convolutions including their junction in the para- 
central lobule controls the motions of the lower ex- 
tremity ; the thigh, knee, foot, and toes being governed 
by various parts of this area from before backward in 
the order nam^ed. 

It will be noticed that the parts susceptible of the 



4 BRAIN SURGERY. 

finest and most delicate movements, those directed by 
the most acute sensations, the lips, the fingers, and 
the toes, lie furthest back in the motor area, chiefly in 
the posterior central convolution. Lesions in this con- 
volution almost always cause some loss of tactile 
sensation as well as paralysis, and hence this area is 
thought to be the seat of tactile sensations as well as 
of movements, while some cases point to the localiza- 




FiG. 1.— Diagram (after Eberstaller) of the Fissures and Convolutions of the Con- 
vexity of the Right Hemisphere of the Brain. The relative depth of the fissures 
is indicated by the shading. The extent of the fimctional areas is indicated by 
the dotted lines. 



tion of muscular sensations in the area just behind 
that of motion. 

The median surface of the hemisphere in front 
of the paracentral lobule is known to be related to 
movements of the trunk in monkeys, but these 
movements are rarely affected by disease in man and 
their cortical representation is still uncertain, though 



THE DIAGNOSIS OF CEREBRAL DISEASE. 



a case reported by Horsley ' points to the cortex in 
front of the leg area on the convexity as the probable 
location of the trunk area. 

There are no sharply defined sections of the motor 
area to be assigned to special motions. Each motion, 
each part of a limb, has a wide general representation 
over the cortex and a special representation at a lim- 
ited area. Horsley says that the areas of representa- 




FiG. 2.— Diagram of the Fissures and Convolutions of the Convexity of the Left 
Hemisphere of the Brain. The speech areas are shown on this hemisphere. The 
motor area is more extensive than on the right hemisphere. 

tion of different limbs merge into one another ; thus 
in the representation of the thumb we find that there 
is a focus, but that the thumb is represented over a 
great deal of the upper limb region, and that this rep- 
resentation diminishes in intensity gradually as we 
pass from the focus upward. This explains the fact 
that the excision of a small area does not totally para- 
^ Amer. Jour. Med. Sci., April, 1887, Case III., Fig. 18. 



; 6 BRAIN SURGERY. 

\ lyze the portion of the limb represented chiefly on 

I that area. The adjacent areas represent to some ex- 

f tent that limb and hence can govern it if need be. 

j (2) TJie speech areas (Fig. 2) are of four kinds and 

in four locations. They are limited to the left hem- 
isphere in right-handed persons and to the right hemi- 
sphere in left-handed persons. There is the motor 
speech area in the posterior part of the third frontal 
convolution, in which the movements concerned in the 
|. act of speaking are controlled. The use of language 

and the power of talking are affected when this re- 
gion is destroyed. There is the audit ory speech area 
in the first and second temporal convolutions, in which 
the memories of word sounds are stored up. The un- 
derstanding of language and the powder of recollecting 
the names of objects are lost when this region is de- 
stroyed. There is the visual speech area in the lower 
parietal region, in which the memories of printed 
words are stored up. The understanding of written 
language and the power to read are lost when this re- 
gion is destroyed. The poicer of writing is a part of 
speech and is usually lost when the motor speech area 
is destroyed, but its exact location is not fully deter- 
mined; some cases pointing to the second frontal con- 
volution, others to the lower parietal convolution near 
the hand centre as its probable cortical position. 

(3) The area of sensations of sight (Fig. 3) is lo- 
cated in the occipital lobe of the brain, including the 
cuneus on the median surface and the occipital con- 
volutions on the convexity. The cortex lying in the 



THE DIAGNOSIS OF CEREBRAL DISEASE. 7 

calcarine fissure is the part primarily reached by the 
visual impulses, ' but the parts named are also concerned 
in vision. Each occipital lobe receives impressions 
from one-half of both eyes, hence a lesion in one lobe 
produces hemianopsia, a half -blindness in both eyes, 




Fig. 3. —The Median Surface of the Right Hemisphere (after Ecker). The visual 
centre is in the cortex lying within the calcarine fissure, OC, and in the cuneus, 
OZ. The sensations of smell and taste are received in the uncinate convolution, [7, 
and at the tip of the temporo-sphenoidal lobe. AB shows the position of the para- 
central lobule, which is included in the motor area of the leg. 

the blind field of vision being on the opposite side to 
the lesion. 

(4) The area of sensations of sound (Fig. 2) is lo- 
cated in the first and second temporal convolutions of 
the brain. Each ear is connected with, both hemi- 
spheres ; hence deafness from a unilateral lesion is only 
partial and is not generally noticed. But if both tem- 
poral lobes are destroyed the patient becomes totally 
deaf. 

^ Henschen: " Pathologic des Gehirns, " ii. , 358, 1892. 



8 BRAIN SURGERY. 

(5) The area of sensations of smell and taste (Fig. 
3) is located at the tip of the temporal lohe on its 
under and inner surface, which rests on the sphenoid 
bone. Each lobe is related to sensory organs on both 
sides, and a unilateral lesion does not often produce 
noticeable symptoms. 

There are large areas of the cortex of the brain 
whose function is undetermined. These are much 
more extensive on the right hemisphere than on the 
left. There are no definite symptoms produced, so far 
as we now know, by lesions in these areas ; but the 
negative fact is certain, that lesions in them do not 
cause disturbances of motion, of sensation, or of speech. 

There appears to be a certain relation between the 
frontal lobes of the brain and the higher forms of in- 
tellectual activity, the powers of fixing the attention 
and of reasoning and of self-control. But disease 
here does not cause a loss of any one mental fac- 
ulty, and for the higher powers of the mind a general 
integrity of the entire brain, not of any one part, is 
necessary. When it is considered that every concept 
is made up of numerous memory pictures joined to- 
gether, each of which has a separate location in the 
brain cortex, it becomes evident that to the process 
of thought a healthy state of the entire cortex is 
necessary and also of the white matter beneath it, 
through which the associating fibres pass. And it is 
therefore impossible for a single lesion anywhere to 
cause a loss of memory or of imagination or of judg- 
ment. Yet for the co-ordination of facts into orderly 



THE DIAGNOSIS OF CEREBRAL DISEASE. 9 

series, for comparison, and for analysis of knowledge 
gained through the senses, the healthy state of the 
frontal lobes appears to be necessary. And lesions in 




Fig. 4.— The Projection Tracts joining the Cortex with Lower Nerve Centres. Sa- 
gittal section showing the arrangement of tracts in the internal capsule. A, Tract 
from the frontal lobe to the pons, thence to the cerebellar hemisphere of the opposite 
side; ^, motor tract from the central convolutions to the facial nucleus in the pons 
and to the spinal cord ; its decussation is indicated at K; C, sensory tract from pos- 
terior columns of the cord, through the posterior part of the medulla, pons, crus, and 
capsule to the parietal lobe; jD, visual tract from the optic thalamus (OT) to the oc- 
cipital lobe; E, auditory tract from the inter-geniculate body (to which a tract pass- 
es from the viii. n. nucleus (J) to the temporal lobe; F, superior cerebellar pe- 
duncle; (t, middle cerebellar peduncle; H, inferior cerebellar peduncle; CiV, caudate 
nucleus; CQ, corpora quadrigemina; Fit, fourth ventricle. The numerals refer to 
the cranial nerves. 



the frontal region, especially upon the left side, are 
quite uniformly attended by mental dulness, apathy, 
lack of power of concentration, and imperfect self- 
control. 



10 



BRAIN SURGERY. 



The cortex of the hemispheres upon the base of the 
bram lying on the orbital plate, on the sphenoid and 
temporal bones, and on the tentorium cerebelli has as 
yet no assignable functions, and lesions in these re- 
gions do not produce recognizable symptoms. 

As to the functions of the centrum ovale, it is known 




Fig. 5.— The Association Fibres in the Centrum Ovale. A, Between adjacent convo- 
lutions; 5, between frontal and occipital lobes; C, between frontal and temporal 
lobes, the cingulum; D, between temporal and frontal lobes— lesion of this tract 
causes paraphasia; E, between occipital and temporal lobes— lesion of this tract 
causes word-blindness ; CA^, caudate nucleus; OT, optic thalamus. 

that through this region the great brain tracts pass in 
various directions (Fig. 4) . Many of these connect 
the various areas of the cortex with their respective 
sensory or motor mechanisms in the base of the brain 
and spinal cord. Others join the different areas of 
the cortex with each other, this bringing about a com- 
bination of sensory impressions into a single mental 
image (Fig. 5). Others again unite the two hemi- 



THE DIAGNOSIS OF CEREBRAL DISEASE. 11 

spheres of the brain with one another, it being certain 
that symmetrical areas must act in unison on the two 
sides. 

The basal gangha, the corpora striata, and optic 
thalami, lying deep within the hemispheres, are masses 
of gray matter whose function is undetermined. Le- 
sions in them frequently affect the various tracts which 
pass between them in the internal capsule, thus cutting 
off afferent or efferent impulses to and from the cor- 
tex and causing sensory and motor symptoms of the 
nature of hemiansesthesia, hemianopsia, and hemi- 
plegia (Fig. -1). But if disease in the ganglia does 
not invade the internal capsule it cannot be detected 
during life. 

The crura cerebri, pons, and medulla contain the 
centres of the various cranial nerve nuclei, and hence 
cranial nerve palsies are caused by disease in them. 
They transmit motor and sensory tracts to the spinal 
cord, hence numerous symptoms appear when they 
are injured.' 

The cerebellum, lying in the posterior cranial 
fossa beneath the tentorium cerebelli, controls the 
equilibrium of the body; hence disturbances of the 
nature of staggering and vertigo are produced by 
lesioDs affecting it, especially if its median lobe is 
involved. 

These local symptoms of brain disease must form 
the chief guides to the physician in his diagnosis and 

^ For a fuller statement of these facts of localization the reader 
is referred to my book, " Familiar Forms of Nervous Disease." 



12 



BRAIN SURGERY. 



to the surgeon in operations. When they are present 
they point to a particular area of the organ which 
must be involved. When they are absent both neu- 




FiG. 6.— Photograph (Fraser) Showing the Relations of the Cerebral Hemi- 
sphere, the Cerebellum, the Cranial Nerves, the Upper Spinal Cord and Cervical 
Nerves to the Surface of the Head. The figures 1, 2, 3, are placed upon the chief 
convolutions of the frontal, parietal, occipital, and temporal lobes of the hemi- 
sphere. 



THE DIAGNOSIS OF CEREBRAL DISEASE. 



13 



rologist and surgeon are as helpless as they were before 
any of these facts of localization were determined. 

Cases open to Operation. 

There are many cases in which it is evident that 
brain disease is present, but in which it cannot be 





Ftg. 7.— Photo^aphof a Cast of a Head showing the Relation of the Cranial 
Sutm-es to the Cerebral Fissures and Convolutions. F, Frontal ; P, parietal ; O, occi- 
pital ; T, temporal lobes ; S, fissiire of Sylvius ; R, fissure of Rolando ; /, inter- 
parietal fissTu-e ; P O, parieto-occipital fissure ; A P, anterior and posterior central 
convolutions. 

located because the necessary symptoms to determine 
its location are absent. 



14 



BRAIN SURGERY. 



There are other cases in which it is evident that the 
disease is located deep within the hemispheres or on 
the base of the brain entirely bevond the reach of the 
surgeon. 

It is therefore evident that only in a limited number 



{. distcnz 



Occiv 
prctu, 




Glabella 



Fig. 8.— Diagram Showing the Measurements Required to Determine the Position 
of the Fissures of Rolando and Sylvius. 

of cases of brain disease can any operative interference 
be considered with favor. 

Operations may be performed for the relief of epi- 
lepsy, for the cure of imbecility, for the removal of 
clots, for the opening of abscesses, for the excision of 
tumors, for the relief of intracranial pressure— with 
or without drainage of the lateral ventricles — and for 
the cure of traumatic insanity. In the following 



THE DIAGNOSIS OF CEREBRAL DISEASE. 



15 



chapters each of these conditions will be discussed, the 
pathology of the disease being especially considered, 
and the results of operations hitherto done being fully 
described. 

Cixuiio- Cerebral Topography. 

The fact that the brain may be exj^osed for the re- 
moval of diseased parts in appropriate cases has made 




Fig. 9.— The Guiding Lines of Reid and the Relation of the Chief Convolutions 

to them. 

it necessary to ascertain the relation of its different 
fissures and convolutions to the cranial sutures, or to 
certain landmarks upon the surface of the head. These 
relations are well shown in the figure (Fig. Y), which 
is a photograph of a cast of a head made immediately 
after death by Dr. Cunningham, of Dublin.' Numer- 

1 See Dublin Journ. Med. So., 1888, p. 157. For an opportunity 
of photographing this cast I am indebted to Dr. F. Ferguson, Cura- 
tor of the Museum of the New York Hospital. 



16 



BRAIN SURGERY. 



ous rules have been laid down for the determination 
of the location of various parts of the convex surface 
of the hemisphere upon the head. The most impor- 
tant are the following, which may he compared with 
the diagram (Fig. 8), and with Eeid's figures (Fig. 9). 




Fig. 10.— The lines indicating the fissures of Rolando and Sylvius laid down on the 
skull according to the rules given in the text and the relative situation of the func- 
tional areas of the cortex to these lines : the right hemisphere. 

To find the fissure of Eolando, lay down a line from 
the root of the nose to the occipital protuberance over 
the top of the head, and take a point 0.557 of the 
distance back upon this line. This point will corre- 
spond to the upper end of the fissure. The fissure 
makes an angle of 67° with the median line just 



THE DIAGNOSIS OF CEREBRAL DISEASE. 



17 



measured. Hence if two strips of metal fixed to one 
another at this angle be placed on the head with their 
junction upon the upper end of the fissure, when one 
strip is on the median line the other strip, pointing 
forward and downward, must lie over the fissure of 




Fig. 11.— The lines indicating the fissures of Rolando and Sylvius laid down on 
the skull according to the rules given in the text and the relative situation of the 
functional areas of the cortex to these lines: the left hemisphere. 

Rolando. In its lower third the fissure becomes a 
little more vertical than the strip. The fissure is 
about three and a half inches long. 

To find the fissure of Sylvius, lay down a base line 
from the lower margin of the orbit to the auditory mea- 
tus. Lay down a second line parallel to the base line 



18 BRAIN SURGERY. 

from the external angular process of the frontal bone 
backward one inch and a quarter and then measure 
upward one quarter of an inch ; this gives point one. 
Find the most prominent part of the parietal emin- 
ence and from it draw a line downward perpendicu- 
lar to the base line, and on this take a point three- 
quarters of an inch below the eminence ; this gives 
point two. Join these two points and the line will lie 
over the fissure of Sylvius. The anterior limb of the 
fissure will be two inches behind the external an- 
gular process. The fissure of Sylvius is about four 
inches long. 

To find the parieto-occipital fissure, continue the line 
of the fissure of Sylvius to the median line. At their 
junction lies this fissure. Since all areas now open 
to surgical operation can be located with a definite re- 
lation to these three fissures, no further rules are nec- 
essary. Since in opening the skull it is customary to 
make a fenestra of at least an inch in diameter, and 
it is frequently necessary to enlarge the opening much 
more, a procedure in no way dangerous under aseptic 
conditions, there is no difficulty in recognizing the 
fissures and convolutions exposed if the rules are 
closely followed. Prior to the large incision of the 
scalp it is well to mark certain points upon the skull 
by the sharp point of a scalpel, so that when the bone 
is laid bare surface landmarks may still be kept in 
view. 



CHAPTER II. 

TREPHINING FOR EPILEPSY. 

The Varieties of Epilepsy. Jacksonian Epilepsy. The Motor Form of 
Attack. The Sensory Form of Attack. The Aphasic Form of At- 
tack. The Psychical Form of Attack. Traumatic Epilepsy. The 
Operation for Epilepsy. Records of Cases of Epilepsy operated 
upon, Personal and Selected. The Pathology of Jacksonian and 
Traumatic Epilepsy. The Results of Trephining for Epilepsy. 
Conclusion. 

The operation of opening the skull for the relief of 
epilepsy is supposed to be one of the oldest in the his- 
tory of surgery. That its results were unfavorable is 
demonstrated by the fact that it fell into disuse and 
for several hundred years was entirely abandoned. It 
is within the past decade that it can be said to have 
become a rational operation, for it is only within that 
time that a definite guide to the surgeon has been 
offered by the facts of the localization of brain func- 
tions. 

The Varieties of Epilepsy. 

Hughlings Jackson was the first to point out a radi- 
cal distinction to be observed between two classes of 
epileptic patients. In one class the convulsion begins 
suddenly with little or no v/arning but usually with a 
cry, and at once the patient loses consciousness and 
falls in a general convulsion which involves all the 



20 BRAIN SURGERY. 

muscles of the body simultaneously. This lasts sev- 
eral minutes and is followed by a deep sleep for some 
hours. This is ordinary idiopathic epilepsy, the origin 
of which is still unknown. 

In the second class of cases the attack begins with a 
conscious sensation in some particular region of the 
body, either in one-half of the face or in one extremity. 
The sensation is followed by a twitching of the mus- 
cles of the part and the sensation and spasm advance 
gradually from the part originally affected to other 
parts in a definite order of progress ; thus, from the 
right half of the face down the right side of the neck 
to the right arm and lastly to the right leg ; or in the 
reverse order, from leg to arm and then to face; or 
from the arm upward to the face or downward to the 
leg. During such an attack consciousness is not usu- 
ally lost, though it may be lost when the attack cul- 
minates in a general convulsion. Such an attack is 
very often followed by a feeling of great weakness in 
the part convulsed, which weakness gradually passes 
away. This form of attack is known as Jacksonian 
epilepsy. 

Jacksonian Epilepsy. 

As far back as lS6i Jackson maintained that this 
form of ejDilepsy was uniformly due to organic disease 
of some kind, situated in the convolutions adjacent to 
the fissure of Rolando. The discoveries of physiolo- 
gists, made between 1872 and 1880, that electrical 
irritation of the corresponding convolutions in ani- 



TREPHINING FOR EPILEPSY. 21 

mals would produce spasms of a similar character, af- 
forded startling confirmation of Jackson's statements. 
And the subsequent collections of carefully observed 
cases of disease in man accompanied by records 
of autopsies made by Charcot/ by Nothnagel/ by 
Wernicke,' by Ferrier,' by Roland," and by myself" 
prove conclusively that disease of an organic character 
located in the motor region of the brain, of a character 
to produce irritation, will uniformly cause Jacksonian 
attacks. The character of these attacks, their mode 
of onset, and the order of their progress depend entirely 
upon the exact position of the initial irritation in this 
motor area. If the irritation is slight it may be lim- 
ited to a small region, if more severe it extends to 
adjacent regions. This extension may be likened to the 
ripple on a pond when a stone is thrown into it. The 
ripple spreads from the centre to the very limits of the 
pond, but the little waves get lower as they get far- 
ther away from their point of starting. Irritation in 
the brain is likewise always more intense at the seat 
of excitation and grows less severe as the irritation 
reaches other centres at a distance. The order of 
progress of the spasm depends entirely upon the rela- 

^ Charcot et Pitres : " Localizations Cerebrales, " Eev. de Med. , 
1879 and 1883. 

^ Nothnagel : " Topische Diagnostik der Gehirnkrankheiten, " 
1879. 

^ Wernicke: "Gehirnkrankheiten," 1881, 

'^ Ferrier: " Localization of Brain Disease," 1878. 

^ Roland: "De I'Epilepsie Jacksonienne, " Paris, 1887. 

^ Starr: "Cortical Lesions of the Brain," Amer. Jour, Med, Sci., 
1884, Jan. , April, July. 



22 BRAIN SURGERY. 

tive situation of the motor centres to one another. 
Thus the fact that the motor centres for the arm lie 
between those of the face and leg determines the fact 
that a spasm beginning in the face always extends to 
the arm before it reaches the leg, or vice versa. It 
has already been stated that Jacksonian attacks usu- 
ally begin with a sensation of tingling or numbness in 
the part convulsed. This tingling is thought to be 
evidence of an irritation of the centres of tactile sen- 
sation of the cortex, which coincide in situation with 
the motor centres. The paralysis which follows the 
attack and is evidence of exhaustion of the motor cen- 
tres is often found to be associated with partial loss of 
sensation, which is evidence of a similar exhaustion of 
the sensory centres. 

What is true of these tactile centres has been found 
to be true also of the sensory centres of sight, and 
hearing, and taste, and smell. Each of these centres 
may be irritated by disease, with the result of produc- 
ing hallucinations, and then be exhausted, with the 
result of producing loss of the power of perception. It 
is thus possible to recognize what has been termed a 
sensory equivalent of a Jacksonian attack, and such 
a sensory equivalent or sensory epilepsy in any one 
sense is just as diagnostic of a localized disease in the 
brain as is a Jacksonian spasm. Sensory epilepsy be- 
ginning with a sound indicates irritation in the tem- 
poral region; sensory epilepsy beginning with light 
before the eyes or an hallucination of sight indicates 
irritation in the occipital region ; sensory epilepsy be- 



TREPHINING FOR EPILEPSY. 23 

ginning with smells or taste indicates irritation in the 
temporo-sphenoidal region. These facts are so abun- 
dantly confirmed by clinical observation followed by 
autopsies that it is needless at present to cite cases in 
proof. ' 

Another form of attack requires mention. It is the 
aphasic form. It has been frequently observed that 
when a Jacksonian attack begins v/ith spasm in the 
right side of the face it is usually associated with an 
immediate inability to speak. This continues until 
the attack is over, and even for several hours after- 
ward. In a number of cases such an inability to speak 
coming on suddenly is the only symptom of the at- 
tack. This then may be termed an aphasic form of 
epilepsy. It is due to irritation followed by arrest 
of function in the motor speech area, which in right- 
handed persons is in the third frontal convolution of 
the left hemisphere of the brain, and in left-handed 
persons in the right hemisphere. There is probably a 
form of aphasic attack due to suspension of function 
of the sensory areas of speech, characterized by a sud- 
den but temporary inability to understand language 
and to read. But such attacks have not to my knowl- 
edge been recorded. 

The last form to be noticed is the psychical epileptic 
equivalent, a form of attack consisting of a temporary 
mental aberration either of the nature of maniacal 
excitement or of simple bewilderment followed by 

^ See Pitres : "Des epilepsies partielles sensitives," Arch. Clin. 
de Med. de Bordeaux, 1892, Jan. 



24 BRAIN SURGERY. 

stupor and loss of memory of what has happened in 
the attack. This probably indicates an irritation fol- 
lowed by suspension of function in the frontal region, 
but any more definite statement is as yet unwarranted. 
The facts just stated prove that Jacksonian attacks, 
either motor or sensory, or aphasic or psychical in na- 
ture, are to be regarded as symptoms of disease and 
are very different in their significance from attacks of 
ordinary epilepsy. Their character denotes the exact 
position of the disease in the brain, and hence such 
an attack may be regarded as a guide in the surgical 
treatment of epilepsy. 

Cases open to Trephining. 

It is evident, then, that the surgeon of the present 
day is no longer in the position of the surgeon in the 
past centuries, when asked to trephine in a case of 
epilepsy. For now it is possible to make a rational 
selection of cases, to choose those which are due to 
local disease, and to put one's finger on the diseased 
spot before the knife is used. It is these cases in which 
such a guide is afforded by our knowledge, which are 
open to surgical interference. The ordinary idiopathic 
epilepsy is as far removed from surgical treatment to- 
day as it was in the past. 

It is difficult to make any general statement regard- 
ing the relative number of cases of epilepsy which are 
open to surgical treatment. I can only state that of 
427 consecutive cases of epilepsy of which I have per- 
sonal records, 26 were considered of organic origin and 



TREPHINING FOR EPILEPSY. 25 

suitable for operation because it was possible to locate 
the lesion with ai^proximate certainty. 

The disease in the brain which gives rise to Jackson- 
ian epilepsy may be of various kinds. Any affection 
of the meninges, whether pachymeningitis or lepto- 
meningitis, of traumatic or of syphilitic or of tubercu- 
lar origin ; or new growths upon or in the cortex of 
the brain; or cysts formed as the result of small cir- 
cumscribed hemorrhages, or of spots of softening from 
embolism or thrombosis of a cerebral artery; or cir- 
cumscribed encephalitis or sclerotic patches may act 
as centres of irritation in the cortex of the brain. The 
majority of these forms of disease when exactly local- 
ized in a small area appear to be traceable to trauma- 
tism, either to a blow or fall on the head, or to a frac- 
ture of the skull with or without depression. In the 
cases soon to be studied some of these pathological 
conditions will be described which have been found at 
the time of operation. 

The discovery of the fact that such pathological re- 
sults of traumatism will produce localized spasms when 
situated in the motor area of the brain has naturally 
led to the conclusion that similar products anywhere 
in the brain may give rise to epilepsy. 

Traumatic Epilepsy. 

It is well known that many cases of ordinary epi- 
lepsy are traceable to injuries of the head and that 
many cases of fracture of the skull have been followed 
by the development of epilepsy. These cases have 



26 BRAIN SURGERY. 

been grouped together under the term "traumatic 
epilepsy," and it has been thought that the traumatism 
could be taken as the guiding indication to the sur- 
geon for the operation of trephining. That wounds 
about the head are much more likely to produce epilepsy 
than wounds in the rest of the body is very well proven 
by statistics of the Franco-Prussian war. The records 
of that war show that among S,9S5 individuals wound- 
ed on the head 46 developed epilepsy; that among 
77,461 persons wounded in the body or extremities 
only 17 became epileptic. The records of our own war 
do not give any statements that bear upon this sub- 
ject. There seems to be no doubt among surgeons 
that epilepsy develops subsequently to injuries of the 
head more of ten than after injuries of other parts. In 
these cases the same distinction already considered 
between general convulsions and localized motor, or 
sensory or aphasic attacks is frequently observed. If 
the character of the attack indicates disease in a defi- 
nite area of the brain, and if the injury of the skull is 
so located as to coincide with this area, then the sur- 
geon has a double indication to guide him in the oper- 
ation. When, however, the injury and the localizing'^ 
symptoms do not coincide, it is better to follow the 
localizing symptoms rather than the surgical injury. 
Thus in two cases operated upon by Dr. McBurney 
depressed fractures existed, epileptic attacks had de- 
veloped subsequently to them, but the fit which began 
in both patients in the arm indicated disease in the 
middle third of the motor area, while the position of 



TREPHINING FOR EPILEPSY. 27 

the fracture was at least two inches away from this 
spot. In both cases trephining demonstrated the 
presence of sph'nters of bone cracked off from the inner 
table of the skull and embedded in the brain in the 
motor area for the arm, with the development of cysts 
at the same place. And the removal of the irritating 
focus of disease produced a cure. In these cases had 
the surgical indication — the depressed fracture — been 
followed the actual cause of the epilepsy would not 
have been found and removed. It is, therefore, far 
better when both medical and surgical indications 
exist, but do not coincide, to follow the medical in- 
dication. 

In any case of localizable epilepsy when no remova- 
ble lesion is discovered at the time of operation, it is. 
the practice of some surgeons to determine accurately 
the area in the cortex irritation of which by a mild 
faradic current will cause a spasm similar to that oc- 
curring in the disease, and then to excise this area. 
The resulting paralysis due to excision of a small part 
of the motor area gradually passes away, and the 
result of the excision is in some cases to remove the 
centre of irritation, and thus to cure the attacks. 

There is, finally, a class of cases following trauma- 
tism in which the epilepsy is of the general type and 
in which there are no localizing symptoms. When 
these are attended by depressed fracture, it is the 
practice of surgeons to trephine at the area of injury, 
that being the only guide obtainable. Lesions are 
sometimes discovered involving the meninges or brain. 



28 BRAIN SURGERY. 

and occasionally the fits are relieved by the operation. 
More often nothing is found at the place of trephining, 
and no result is obtained. In this class, where definite 
symptoms pointing to a focus of disease do not exist, 
the operation must be regarded as entirely exploratory. 

The Danger of Trephining. 

The records of cases of epilepsy in which the opera- 
tion of trephining has been undertaken are at present 
very numerous. The operation has been done over 
300 times within the past fiYQ years, with very few 
deaths. Laurient {Jour, cle Med., de Chiriir. et de 
Pharmac, May 20th, 1891) collected 102 cases of tre- 
phining for e^Dilepsy, with the result as follows: 5-1 
cured; 20 improved; 1 7 not improved ; 2 made worse; 
7 died. Agnew (Trans. Amer. Surg. Assoc, Sept., 
1891) collected 57 additional cases with result as fol- 
lows : 4 cured ; 32 improved ; 9 not improved ; 4 un- 
known result; 1 died. 

The cases collected here number 12, with result as 
follows: 13 cured; 11 imjDroved ; 15 not improved; 3 
died. Of these cases thirteen are my own. 

The statistics are chiefiy of value in demonstrating 
the safety of the oiDcration. The average mortality 
is 7^. It seems needless to relate very many cases 
in full. The essential features will be illustrated in 
the histories of cases which have been under my own 
observation. For the sake of presenting a sufficient 
number of cases to secure some credence for the state- 
ments made, I have appended an account of about 30 



TREPHINING FOR EPILEPSY. 29 

cases in which the reports are sufficiently exact and 
sufficiently reliable. These have been selected entirely 
from American reports. In some of these cases the 
fits were so exactly localized that a diagnosis could be 
made without difficulty. In others the existence of a 
depressed fracture or scar of the scalp was taken as a 
guide to the surgeon. The majority of the cases were 
traumatic in their origin. 

Cases of Epilepstj Trephined. 

Case I. Trauma — Spasms of right hand — Splinter of 
hone in motor area — Cyst of the Pia mater — 
Recovery. 

A. B., aged 18, was perfectly well until April, 1891, 
when he was struck by a heavy block of wood falling 
on his left parietal bone. His skull was fractured and 
he was taken to a hospital and treated there for several 
weeks, but not trephined. Three weeks later he began 
to suffer from peculiar attacks which had continued at 
frequent intervals until the day of operation, November 
9th, 1892. His attacks are all of the same character. 
They begin with a tingling and numbness in his right 
hand which extend up the arm to the shoulder, down 
the trunk and down the leg ; the tingling is never felt in 
the face. Soon after the tingling begins in the fingers a 
twitching motion is felt in the hand, and the clonic spasm 
extends up to the shoulder, involving the entire arm ; it 
never extends to the leg or face. He does not lose con- 
sciousness during the attacks; the attacks last about a 
minute and subsequently he feels a little weak in the 
arm for a short time; he has no difficulty with his 
speech. Between the attacks there is neither paralysis nor 
anaesthesia; he does not suffer from headache; his 
eyesight is good. 

Examination of the head showed the existence of a de- 



30 



BRAIN SURGERY. 



pression about an inch long parallel to the longitudinal 
fissure and about an inch to the left of the median line 
anterior to the vertex. When the fissure of Rolando was 
laid down upon the head, this depression was found to lie 
over the first frontal convolution. A second scar was 
found below the first at a position over the hand area. It 
was determined to disregard the surgical indication, viz., 
the fracture, and to trephine over the hand centre of the 




£>.3r. 12.— The Situation of the Opening made in the Skull in Case T. The position 
of the fracture is also showu. 

'Cortex. This Avas done November 9th, 1892, by Dr. 
McBurne}'. 

After the scalp was retracted the attempt to strip up the 
periosteum revealed the fact of its close adhesion to a 
fissure in the bone passing directl}' forward from the junc- 
tion of the middle and lower thirds of the fissure of Ro- 
lando. It was evident that at this line there had been a 
fracture of the skull which could not be detected by palpa- 
tion of the scalp. A trephine opening of one and one- 



TREPHINING FOR EPILEPSY. 31 

quarter inches in diameter was made at the point indicated 
in the figure over the hand centre (Fig. 12). 

When the button was removed the dura was found to 
be close!}' adherent to it, and in the dura was found im- 
bedded a splinter of bone one inch long and three-fourths 
of an inch wide. This lay partly outside of and partly in- 
side of the dura, it having evidently been thrust through 
the dura at the time of the fracture. The dura about it 
was thickened to one-sixteenth of an inch. The splinter 
of bone was cut out and removed. A thickened con- 
nective-tissue strip which formed the external wall of a 
cyst was found adherent to its inner surface and removed 
with it. During the removal about a drachm of clear serous 
fluid escaped from the cyst, and a vessel of the pia was un- 
avoidably torn in the removal of the cyst wall, giving 
rise to considerable hemorrhage. The appearance of the 
brain as seen through the opening in the dura was normal, 
though some oedema of pia over it was evident. The bone 
was not replaced. The wound was closed and healed by 
first intention within a week. 

The situation of the splinter of bone was such as to have 
produced irritation in the hand area of the cortex. 

The boy had two very slight attacks subsequently to the 
operation, but after that up to March, 1893, had none 
whatever and was apparently well. 

Case II. Trauma — Spasms of right hand — Cyst re- 
moved — Recovery for six months. Recurrence — 
Second trephining — Recovei^y. 
Male, aged 14, at the age of 4 had a severe fall fractur- 
ing his skull over the left coronal suture. As a result 
of this he developed right hemiplegia with partial right 
hemiansesthesia, but without any aphasia. Traces of this 
hemiplegia still remain. At the age of 12| he had a 
second fall, hit upon his head, and soon after this he 
began to suffer from Jacksonian epilepsy. His fits 
always began with a tingling and spasm in the right 
hand which extended to the arm and then down the right 



32 



BRAIN SURGERY. 



leg, the face being very rarely involved, though oc- 
casionally the head turned to the right. There was no 
loss of consciousness during the attack. It lasted about 
a minute and he felt slightly weaker in the arm and leg 
after it. He has had as many as six attacks in a day. 
The boy was mentally very bright and had no headache. 
Evidence of an old depressed fracture was found in 
the skull, the depression extending forward over the first 




Fig. 13.— The Situation of the Opening made in the Skull in Case II. 



frontal convolution so that its position was decidedly 
anterior to the motor area of the arm. Medical treatment 
having failed to relieve these attacks, it was resolved to 
trephine. The point selected was the arm centre in the 
middle third of the central convolutions, though its position 
was an inch and a half posterior to the position of the old 
fracture (Fig. 13). Dr. McBurney operated at Roosevelt 
Hospital, January 30th, 1892. 

On exposing the dura it was found adherent to the bone 



TREPHINING FOR EPILEPSY. 33 

and did not pulsate. When the dura was dissected back 
it was found adherent to the pia, which was thickened and 
opaque so that the brain was not visible beneath it. On 
dividing the pia a cjst was found lying upon the surface 
of the brain and from this a drachm of clear fluid was evacu- 
ated. The cyst had lain in. the pia itself . The walls of 
the cyst were removed. A strand of thickened pia was 
found running forward toward the old scar. The opening 
in the bone was, therefore, enlarged in the direction of the 
old fracture until this was reached and a second cyst was 
found beneath the old fracture. This cyst was also evac- 
uated of about two drachms of fluid and its walls taken 
away. The brain beneath the cysts appeared to be some- 
what atrophied but pulsated normally. It had an appear- 
ance of being slightly more yellow than normal brain 
tissue, and the number of blood-vessels and capillaries- 
over its surface seemed to be rather increased. The wound 
was closed and healed well, and from January 30th, 1892,. 
the date of operation, until April the boy had no fits at all. 
He then returned to my clinic, complaining of a return of 
his old attacks. On examination of the head it was found 
that there was a small collection of pus beneath the scalp 
over the site of the opening in the bone. This pus was 
evacuated and the small abscess cavity at once healed. 
From that date until August, 1892, the boy had no at- 
tacks. Then his attacks began again, and increased in 
frequency until in December he was having three or four 
daily. These attacks began with tingling and twitching 
in the right hand which extended up the arm and shoulder, 
then down the side to the leg, arm and leg twitching 
together for the space of from five to fifteen minutes. 
Subsequently to the attacks both arm and leg were slightly 
paretic, the face never being involved, and consciousness 
not being lost. The use of bromides during this period 
had no effect upon the increase of the attacks ; he was, 
therefore, again advised to go into the hospital for opera- 
tion. On January 7th, 1893, Dr. McBurney operated. On 



34 BRAIN SURGERY. 

exposure of the shaven head the scalp was seen to be thick 
and tense so that at no place was there any perceptible 
depression around the old scar or over the defect in the 
bone. Pulsation of the brain was perceptible by palpation 
over the area from which the bone had previously been 
removed, and which corresponded to the arm centre. The 
tissues were very much thickened and it was thought best 
to avoid their direct incision. A semilunar incision was 
therefore made, the summit of which passed somewhat 
more to the left of the median line than the preceding 
incision, and by dissecting up its anterior and posterior 
portions the healthy bone below the old trephine opening 
was reached, the scalp being carefully dissected away 
from the old scar tissue. A triangular opening was then 
chiselled in the bone about one and one-half inches long 
and three-fourths of an inch wide. The bone was found 
to be closely adherent to the dura. The dura was seen 
to be thickened and on being divided and turned back it 
was closely adherent to the pia. The pia and brain were 
found to be welded together in a thick connective-tissue 
rnass. Palpation of this gave the impression of fluid be- 
neath it. Puncture with a hypodermic syringe brought 
away a small amount of clear serous fluid from a cavity 
about half an inch beneath the cortex. Incision was made 
into this cavity through the brain above it. When the 
brain tissue was incised it was found to present an abnor- 
mal appearance. There was no clear line of demarcation 
between the cortex and the white matter beneath it, but 
a connective-tissue mass had taken the place of the cortex. 
This mass of tissue was therefore excised, a piece of a lens 
shape about an inch long by half au inch wide being re- 
moved. It appeared to be scar tissue. ^ The second punc- 
ture with a hypodermic needle at a point an inch further 
forward revealed the presence of another cyst, and the in- 
cision in the brain was, therefore, carried forward so as to 

^ The microscopical appearances of this tissue are described by 
Dr. Van Gieson on page 102. 



TREPHINING FOR EPILEPSY. 35 

empty this. Hemorrhage was pretty free, but aftei the 
scar tissue had been excised the sides of the wound in the 
brain were seen to consist of fairly normal gray anc^ white 
substance. The wound was packed with iodoform gauze 
and dressed antiseptically . The next day the boy was very 
comfortable, had no paralysis or anaesthesia. Within two 
weeks the wound had healed. He has had two attacks up 
to March, 1893. 

Case III. Trauma — General convulsions beginning in 
left arm — Splinter of hone in the brain removed — 
Brain sclerotic — Recoveinj, — Recurrence of fits. 

A. G., male, aged 24, met with an injury in April, 1888, 
which produced a fracture of the skull on the right side 
about at the middle of the coronal suture. After the in- 
jury he was ill with fever and delirium about six weeks, 
but gradually recovered. Three j^ears after this injury he 
began to have convulsions, from which he had suffered at 
intervals up to April, 1892, when he was first seen. The 
attacks began with a movement of the left arm and sensa- 
tion of numbness in the left hand and with a turning of 
the head to the left; he then lost consciousness and the 
convulsion became general. He has had as many as two 
fits in a day, and the longest interval during the year 
was nine weeks. He had three fits in March, 1892. He 
was very dull mentally, and had been treated by very 
large doses of bromide of potassium, which diminished the 
frequency of but did not arrest the fits. 

Operation by trephining was performed by Dr. McBur- 
ney on the 2d of April, 1892. The skull was opened at 
the point of fracture over the arm centre on the right side 
(Fig. 14). The external table was found to be fractured 
but the internal table appeared to be uninjured, but a small 
splinter of bone was found indenting the dura. The 
dura was very much thickened and the pia and brain 
were decidedly oedematous and yellower than normal. 
The pulsation in the brain was greater around the 
discolored area than in it. The discolored area pitted 



36 



BRAIN SURGERY. 



upon pressure and to the touch gave the impression 
as if a cyst lay beneath, but puncture in all direc- 
tions with a hypodermic needle failed to reach any cyst. 
A portion of the softened area was cut out. It was exam- 




FiG. 14.— The Situation of the Opening made in the Skull in Case III. 



ined by Dr. Van Gieson, who reported as follows : " I 
find that a splinter of bone has been driven down into the 
dura; the dura is thickened at this place and matted 
together with the pia. Dura is also sharply indented 
where the splinter is impacted. I think that the splinter 
has been much reduced in size by rarefying osteitis (only 
a few interlacing delicate trabeculse remain of the bone). 
The splinter was probably originally much larger. Brain 
substance is much changed, there are too many glia 
cells. The cortex seems to have come from the motor 
region : this I gather from the presence of the very large 



TREPHINING FOR EPILEPSY. 



37 



ganglion cells in the third layer." ' The wound healed 
easil}'. He had no paralysis and in three weeks he was 
discharged from the hospital. At that time he had 
improved very much mentally, and had had no fits. Soon 
after leaving the hospital the fits began again, and in the 
summer they occurred with greater frequency than before 
the operation, and at the present time they are as severe 
as ever. 

Case TV. Trauma — Spasm of right leg — Trephining — 
Death. 
A. D., male, aged 30, had been perfectly well until 
a fall which occurred in 1888. He hit upon his head 




Fig. 15. —The Situation of the Opening made in the Skull in Case IV. 



on the left side, near the vertex, but had no scar re- 
maining as evidence of the fall. Since the fall he had 
begun to have attacks which consisted of a spasm begin- 

^ The microscopical appearances of this tissue are more fully de- 
scribed on page 83, 



38 BRAIN SURGERY. 

ning in the right leg, with a stamping motion of the foot, 
after which he would rise from the chair, if seated, and 
turn to the right, or w^ould turn to the right if the fit came 
on when he was standing. After turning he lost con- 
sciousness, and fell in a general fit. These fits had be- 
come frequent during the past two years, so that he was 
having as many as six a day when he was first seen by 
me at Dr. Weir's request. 

On the 17th of January, 1890, Dr. Weir trephined at the 
'New York Hospital. The opening (Fig. 15) was made 
over the upper third of the motor region, exposing the area 
corresponding to the leg centre. The skull was found to 
be unusually thick, but no evidence of fracture was dis- 
covered. Small white specks resembling miliary tubercles 
were found scattered over the pia and over the motor area 
of the leg on the median surface of the brain. The dura 
was not thick nor adherent. The thickness of the skull 
made the operation a long one, and the hemorrhage was 
considerable, and the patient died of shock. 

Case Y. Traumatic Epilepsij — Hemiplegia tvith athe- 
tosis—Subcortical cyst emptied — Recovery. 

H. L. J., aged 12, was weU until the age of 2, when he 
had a fall upon his head followed by convulsions lasting 
eleven hours. On recoA^ering from convulsions he was 
found to be hemiplegic on the right side and aphasic ; he re- 
covered slowly during the following year, but has never 
been entirely relieved from the condition of right-sided 
paralysis, and has always been slow in his speech and men- 
tally dull. For several years subsequently to the fall he was 
subject to slight attacks of the nature of petit mal ; two j^ears 
ago he had his first attack of grand mal, and since that time 
has had several recurrences. The fits begin by twitch- 
ing of the eyes and head, the right side being always 
more affected than the left side in the convulsion; and 
he loses consciousness. 

He was examined by me on the 2 2d of November, 1892. 
A condition of right hemiparesis with athetosis of the 



TREPHINING FOR EPILEPSY. 



39 



right hand was found, the paralysis being greater in the 
hand than in the face or leg. Mentally he was very defi- 
cient, being able to read but little and being very dull and 
stupid; his speech was slow but he was not aphasic; there 
was no affection of sensation in the paralyzed limbs. 

The diagnosis was made of a traumatic hemorrhage or 
a cyst in the cortex of the brain in the motor zone affect- 
ing especially the arm area. Trephining was recom- 




FiG. 16.— The Situation of the Opening made in the Skull in Case V. 

mended with a view of removing the clot or the cyst 
which was considered the cause of the symptoms. 

On December 2d, 1892, he was trephined by Dr. McBur- 
ney at Roosevelt Hospital, an opening of one and one-half 
inches in diameter being made over the arm area (Fig. 16) . 
The bone and the dura appeared to be normal. On exposing 
the brain the fissure of Rolando was seen crossing the 
opening ; the cortex appeared to be normal, but palpation 
indicated a collection of fluid beneath, and puncture with 



40 BRAIN SURGERY. 

a hypodermic needle resulted in the evacuation of about a 
drachm of clear serous fluid from a cavity three-fourths of 
an inch below the cortex. Incision through the summit cf 
the anterior central convolution gave entrance to this cav- 
ity, and an attempt to drain it was made by inserting a 
small bit of rubber tissue. The dura was replaced but not 
stitched and the scalp was left open over the part of brain 
exposed. The day after the operation the boy was found 
to be in about the same condition so far as power went, 
but the right hand as high as the wrist was decidedly 
anaesthetic to touch, temperature, and pain, but there was 
no affection of the muscular sense. The athetosis had 
ceased. One Aveek after the operation this condition of 
anaesthesia was much less but still remained. It did not 
affect his face, or his leg, or his bodj", or his arm, above 
the wrist. He seemed bright, had no temperature, but 
had had two attacks of petit mal. The wound healed 
readily and he went home at Christmas and has had no 
attacks up to March, 1893. He is said to be much brighter 
mentally and the athetosis has not returned. 

Case VI. Trauma — Spasm in face — Temporary 
aphasia — Trephining — Scar in brain — Recovery — 
Recurrence of attacks. 
J. R., aged 40, was struck upon the left temple 
and sustained a fracture of the skull in August, 
1889. When he recovered consciousness he was found to 
be paralyzed upon the right side and aphasic. In the 
course of the following six months the hemiplegia gradu- 
ally subsided and the speech gradually improved so that 
he was able to go about but was still unfit for work. 
About a 3'ear after the accident he began to have convul- 
sions ; some of these were general with loss of conscious- 
ness, but later they became localized and have remained so 
for the past two years. They have gradually increased in 
frequency until, when seen in December, 1892, he was 
having several attacks every week. The attacks began 



TREPHINING FOR EPILEPSY. 41 

with a twitching of the muscles about the mouth upon the 
right side ; a drawing of all of these muscles toward the 
right with a twitching of the eyes, a gradual extension of 
the spasm to the right side of the neck and to the right 
arm and hand. During the attack he did not lose con- 
sciousness but he could not speak, and had a sensation of 
tingling in the face and mouth. After an attack he ap- 
peared to be weak and was not able to talk as well as 
before the attack. 

Examination on December 10th, 1892, demonstrated a 
slight paresis of the right side of the face, the tongue not 
deviating, and some weakness in the right arm, but no 
affection of the leg ; no disturbance of sensation ; increased 
reflexes upon the right side. His mental processes seemed 
to be slow ; he understood perfectly what was said to him, 
but his replies were slow and his use of language evi- 
dentlj" imperfect ; he admitted that he could not express 
himself as he formerly did. He did not suffer from head- 
ache, but there was tenderness over the left temporal re- 
gion. A depressed fracture of the skull running backward 
two inches about over the position of the Sylvian fissure 
was evident upon palpation. The posterior limit of the 
fracture was an inch below the location of the motor area 
of the face. 

It wa^ thought that beneath the fracture and about 
it some thickening of the meninges had occurred 
with the possible formation of a cyst, as the re- 
mains of an old hemorrhage, and that by an operation 
some relief could be had. On December 19th, 1892, Dr. 
Briddon trephined at the Presbyterian Hospital. A small 
trephine opening was made over the motor centre of the 
face and a larger one an inch below over Broca's convolu- 
tion. The intervening bridge of bone was removed and 
the opening enlarged in all directions by the rongeur, the 
size of the opening being two and one-half by two inches 
(Fig. 17) . On removal of the bone a perceptible thickening 
of the dura, especially over the face centre, was seen. When 



42 



BRAIN SURGERY. 



the dura was divided it was found to be three times its ordi- 
nary thickness and closely adherent to the pia. It was 
stripped off carefully. The pia was found adherent to the 
brain and very oedematous. The brain substance at the 




Fig. 17.— The Situation of tlie Opening made in tlie Skull in Case VI. 

lower part of the anterior central convolution was appar- 
ently replaced by a connective-tissue mass. Where the dura 
was most thickened and its adhesion to the pia and the brain 
closest the brain exposed in the lower half of the opening ap- 
peared softer, darker, and abnormal. A hemorrhage had 
probably taken place, and as the result there remained a 
mass of . scar tissue, chiefly connective tissue, beneath the 
pia mater. When the pia was divided it was found to be 
about a line in thickness. The gray matter of the brain 
had been reduced in its thickness so that the incision into 
the pia showed at once the white matter lying beneath it. 
This condition extended forward beneath the seat of the 
fracture, occupying a space about half an inch wide by an 



TREPHINING FOR EPILEPSY. 



43 



inch long jast above the fissure of Sylvius. The adhesion 
between the dura and the pia was broken up by the handle 
of the scalpel, but it was not thought best on account of 
hemorrhage to attempt the removal of the altered pia and 
brain. The wound was immediately closed and healed 
well by primary union within ten days. 

The patient had two very slight attacks during the fol- 
lowing two months and complained of some stiffness in 
the motion of his jaw. The pathological condition found 
precluded any hope of cure. 

Case YIL Traumatic epilepsy — Trephining — No re- 
sult. 
Male, aged 23, had a fall five years ago, hit upon 
the vertex to the right of the median line and somewhat, 




Fig. 18.— The Situation of the Opening made in the Skull in Case VII. 



anterior to the fissure of Rolando. He soon developed 
general epileptic convulsions which began with a visual 



44 BEAIN SURGERY. 

aura, consisting of a green light before his eyes. The 
attack was of the nature of a general convulsion, with a 
total loss of consciousness; there was no localized move- 
ment. In addition to the general convulsion he had occa- 
sional attacks of petit mal. Physical examination failed 
to show any disturbance of sensation or of motion. He 
was trephined by Dr. McBurne}', June 10th, 1892, over 
the seat of the fracture. The depression was found in the 
external table, not extending to the internal table (Fig. 
18). The dura and pia were found to be normal, and the 
brain presented a normal appearance. The patient re- 
covered from the operation, was out of the hospital in two 
weeks. At his last visit, October, 1892, he was still hav- 
ing his fits, having had five in the past four months. 

Case YIIL Traumatic epilepsy — Spasm in right hand 
— Trephining — Improvement — Eelajjse — Death. 
P. B. C, male, aged 30, was hit in April, 1890, over 
the left side of the head by a sand-bag and was taken to 
the Roosevelt Hospital, where he lay for twelve days in 
a state of unconsciousness. There was no fracture of the 
skull. He gradually" recovered and was able to return to 
his home in the South in July, and on July 23d had two 
fits. Each fit began with tingling and movement in the 
right hand, extending to the face, which was drav^Q to 
the right, and the mouth was opened and closed, then the 
speech was lost. In five minutes the attack had passed off 
and he felt pretty weU. Such attacks were repeated in 
August, September, and October ; all of the attacks being 
of the same character, excepting that on two occasions 
he lost consciousness for a few minutes. Examination 
in October, 1890, failed to reveal any deformity of the 
skull or any evidence of hemiplegia. He was rather slow 
and deliberate in his speech, with some slight hesitation 
for words, but this he maintained was his usual manner. 
His discs were clear, and his pupils equal. He was put 
upon bromide and belladonna, which he continued until 
March, 1891, during which time he had no attacks. 



TREPHINING FOR EPILEPSY. 



45 



Between March and June, he averaged one severe attack 
and three slight attacks every month, all of which were 
similar to the attack first described. After each attack he 
noticed a decided difficulty in his speech, and the slowness 
of speech previously noticed still persisted. While there 
was no apparent clumsiness or anaesthesia in his right 
side, the power in his right hand was 100 as compared 
with 110 in his left. His personal equation was about 




Fig. 19.— The Situation of the Opening made in the Skull in Case VHI. 



normal, hearing being y^^ of a second, sight yV% of a 
second, an average of seven tests being taken. 

It being thought that the injury had probably produced 
a small hemorrhage upon the surface, the remnants of 
which might be removed, it was decided to trephine him. 
The operation was performed in June, 1891, by Dr. 
McBurney, an opening being made over the arm centre, 
and extending downward toward the face and motor 



46 BRAIN SURGERY. 

speech centres (Fig. 19). No evidence of fracture was 
found in the skull, and the dura was not adherent, and the 
brain appeared to be normal. The wound healed perfectly, 
and by December the hole in the skull had become filled 
up by a tense membrane, so it could not be depressed to 
any extent by the finger. He had two attacks between 
June and December. These attacks were of the same 
character as those occurring before the operation. He 
still talked slowly. During 1892, his attacks became 
more frequent, he developed severe headaches and optic 
neuritis, and he finall}^ died in November, 1892. He was 
not under my observation after December, 1891. It is 
probable that there was present in this case a small subcor- 
tical tumor at the time of the operation, which escaped 
detection and afterward grew until it finally caused his 
death. 

Case IX. Trauma — Spasms in left hand — Cyst evac- 
uated — Recurrence of fits. 
A child, aged 3, had had a fall, hitting upon the 
right side of the head, and three months subsequentlj' 
had developed spasms in the left arm which occurred at 
first occasionally, and later sometimes as frequently as 
seven a day. The arm was slightl}' weak. An apparent 
defect in the bone was felt in the right mid-parietal region. 
It was decided to make an exploratory operation. This 
was done by Dr. Poore in October, 1889, at St. Mary's 
Hospital. On exposing the bone a triangular defect was 
found in it with a thick connective-tissue membrane filling 
it (Fig. 20). Beneath this membrane was a cyst which 
was evacuated. The bone was not trephined on account 
of evidence of shock following the evacuation of the cyst; 
the operation was terminated. The child recovered from 
it, was free from her spasms for a year; recovered in the 
mean time the power in the arm. At the end of that 
time, however, the attacks began again. The probability 
is that this cyst has refilled with fluid and a second oper- 
ation is contemplated. 



TREPHINING FOR EPILEPSY. 



4? 



Case X. Trauma — Depressed fracture — Spasm be- 
ginning ivith turning of the head — Trephining — 
Recovery — Recurrence of fits. 
T. M., male, aged 21, had a fall at the age of 7, 
producing an extensive fracture of the left parietal and 
frontal bones, which was immediately followed by right 
hemiplegia and motor aphasia, lasting a year and 
passing off. At the age of 14 he began to have 




Fig. 20.— The Situation of the Defect in the Skull in Case IX. 



general convulsions, which always began with a turning 
of the head to the right and were followed by a loss 
of consciousness. For the past seven years he has 
had such fits at intervals, having had as many as 
five in one day, but under bromide the rate has been about 
one in three weeks. He has not developed mentally in a 
proper way. He has little self-control, is irritable, quar- 
relsome, and ugly. He has fair intelligence, being able 



48 



BRAIN SURGERY. 



to read and write, but is not fit to do any but simple 
work. 

Examination October 14th, 1892, showed a trace of the 
old hemiplegia, the right side being smaller and somewhat 
weaker than the left. His speech was fair but he talked 
with some hesitancy. A depressed fracture of the frontal 
and parietal bones was found over the junction of the 
third frontal and anterior central region on the left side. 




Fig. 21.— The Situation of the Opening made in the Skull in Case X. 



On October 18th, 1892, he was trephined by Dr. Hart- 
ley, at Roosevelt Hospital. On laying back the scalp two 
deep depressions in the skull were found with a long 
angular depression between them (Fig. 21). This lay in 
front of the fissure of Rolando, about opposite to its lower 
third. The skull was very much thickened at the site 
of the old fracture. The bone was cut awav over an area 
about two and one-half inches square. It had evidently 
made considerable pressure upon the tissue beneath. The 



TREPHINING FOR EPILEPSY. 49 

bone was adherent to the dura, and when the dura was 
divided and reflected it was found to be adherent to the 
pia. The pia was thickened and clouded and formed a 
cover of thin white connective tissue upon the brain. The 
cortex beneath the pia looked abnormal. It was rough on 
the surface, appeared redder than the adjacent cortex, the 
pia was closely adherent to it and contained an unusual 
number of capillary vessels. The appearance suggested 
an increase in the connective-tissue elements of the cortex 
with a high degree of vascularization. The brain pulsated 
normally. Puncture through this abnormal tissue failed 
to reveal any cyst beneath it. The wound was closed and 
healed readily, the man being up within a week of the 
time of operation. He had one fit on December 28th, 1892, 
and none since up to March 1893, though he had five the 
week before the operation. His mental condition is 
certainly much better than before the operation. 

Case XL Trauma — Spasm in the right arm — Tre- 
phining — Recovery — Return of attacks. 
E. W., male, aged 11, was perfectly well until January,. 
1890, when he fell, striking upon the left parietal region of 
the skull, cutting the scalp but not fracturing the bone. 
This area was tender some weeks subsequently to the fall, 
and he has had pain in it at times ever since. Soon after 
the fall he began to have attacks, which became frequent, 
which always occurred at night, and which were always 
alike. The attacks began with a closing of the fingers 
and thumb of the right hand and a twitching of the same. 
The arm was then fiexed and trembled, and the hand was 
brought to the face by a movement at the shoulder; the 
face upon the right side then began to twitch, and the 
head turned slightly toward the right. At this point he 
wakened from his sleep, perceived a sensation as if his 
mouth were full on the right side, felt a slight numbness 
in his cheek, but at the moment of waking the spasm 
ceased. The spasm never extended to the leg or to the 
muscles of the other side of the body. The attacks never 
4 



50 



BRAIN SURGERY. 



occurred when he was awake or in the day-time, but as 
many as six have occurred in one night. 

Examination on February 19th, 1892, failed to reveal 
any evidence whatever of disturbance of sensation or 
motion. His mental condition was perfect, his eyes were 
normal, and he had no sj^mptoms to complain of. 

The condition was, therefore, one of pure Jacksonian 
epilepsy in the right hand developing subsequently to a 




Fig. 22.— The Situation of the Opening made in the Skull in Case XI. 

blow upon the head, but without any permanent defect of 
power or sensation. 

The patient was trephined by Dr. McBurne}', on Feb- 
ruary 25th, 1892, at St. Luke's Hospital. The opening 
was two by one and one-half inches over the middle third 
of the fissure of Rolando, and exposing the adjacent cen- 
tral convolutions (Fig. 22). The bone was found to be 
normal, the dura was adherent to the bone, and a small, 
v^hitish plaque of connective tissue was found on the 



TREPHINING FOR EPILEPSY. 51 

dura. The dura was not adherent to the pia, and the 
brain appeared to be perfectly normal; no cyst and no 
remnants of a clot were found. The wound was closed 
and within two weeks the boy was as well as before the 
operation. 

During the month of March he had six slight attacks, 
the face only being affected. During April he had one 
attack ; during June he had two attacks ; since June he 
has had no attacks of the former character. 

During August and between August and October he 
developed a new kind of attack at night which at first 
appeared to be of the nature of somnambulism. These 
were at first occasional, but by October had become as 
frequent as three or four in a night. They could be 
brought on by disturbing him in his sleep, either by noise 
in the room or by shaking him. The attacks consisted of 
the following motions: he closed his eyes tightly for a 
moment, then opened them and looked around, but evi- 
dently saw nothing consciousl}^, as he did not recognize 
any one present or reply to a question addressed to him. 
His lips then twitched slightly, as if an attempt were 
being made to whistle, and the mouth then opened slowly 
and was held wide open for a few seconds ; he then appar- 
ently tried to rise up in bed, and sometimes succeeded in 
getting up upon his knees. There was no convulsive move- 
ment of the limbs whatever. Usually after a few seconds 
he lay down again, took a long breath, followed by two or 
three short breaths, and then the attack was over. Occa- 
sionally he woke up, and if so he always knew that some- 
thing had occurred, but was unable to give any account of 
what the sensation was which enabled him to distinguish 
such a waking from that from ordinary sleep. He was 
perfectly well in the day-time, and is a very bright and 
active boy. I witnessed two of these attacks. 

The boy's father was for many years a sleep-walker, 
and the boy is known to have walked in his sleep. He is 
a restless sleeper, and frequently talks in his sleep. For 



52 BRAIN SURGERY. 

this reason these attacks were thought to be of a somnam- 
bulistic nature. But during November they become more 
severe and a decided convulsive movement of the arms 
and legs developed. The limbs were all rigidly extended 
and trembled violently, the right hand was flexed, the left 
hand extended, and after the attack he drooled at the mouth 
and breathed stertorously for a minute or two. 

Treatment by gradually increasing doses of tincture of 
belladonna, from five drops every night up to thirty-five 
drops every night, had little or no influence upon the at- 
tacks. On December 20th, 1892, he was put upon bro- 
mides which immediately reduced their number and sever- 
ity, and he is upon bromides at the present time, March 
1893, and is entirely free from attacks. 

Case XII. Traumatic epilepsy — Trephining — No 
result. 
Male, aged 50, had had a fall several years before 
the time when he was first seen, March, 1892. Sub- 
sequently to the fall he had developed fits, beginning in 
the right hand. He had been trephined in 1891, in Bur- 
lington, Vt. The hand centre had been exposed, but noth- 
ing had been found and the fits had continued. On 
examination an old fracture of the skull was found in the 
frontal bone anterior to the motor region of the brain. As 
he was anxious to be operated upon, trephining was done 
by Dr. McBurney at the seat of this fracture. The frac- 
ture was found to involve the external table only, the in- 
ternal table not being affected (Fig. 23). The dura ap- 
peared to be normal, as did also the pia and brain. The 
wound healed readily and he was discharged from the 
hospital in two weeks. At the date of last report, October, 
1892, his fits continued as before. 

Case XIII. Trauma — Epilepsy. — No result. 

J. F., aged 32, had a severe fall when a boy about nine 
years of age, leaving a scar over the left parietal bone. 
When 23 years of age he began to have epileptic attacks, 



TREPHINING FOR EPILEPSY. 



53 



consisting of general convulsions with epigastric aura. 
He had had since that time as many as five fits a day, 
and was having two or three every week when first seen 
by me, March 1st, 1890. The attacks did not begin 
uniformly, in any one set of muscles, but were general. 
In addition to the convulsions he had attacks of petit 
mal, daily. His attacks were so frequent as to unfit him 
absolutely for work of any kind, but had not apparently 




Fig. 2.3.— The Situation of the Opening made in the Skull in Case XII. 



affected his intellect to any extent. Examination showed 
no evidence whatever of disturbance of sensation or of 
motion. Bromides had failed to control the attacks, 
though reducing their frequency somewhat. He was 
trephined on the 8th of March, 1890, at the Roosevelt 
Hospital, by Dr. McBurney. The old scar was exposed, 
the fracture in the external table was found (Fig. 24). 
A section of bone two by three inches in diameter was 



54 



BRAIN SURGERY. 



removed. There was no fracture of the internal table. 
There was no affection of the dura and pia and the brain 
appeared to be normal. 

He recovered from the operation and was able to leave 
the hospital in two weeks. On April 1st his attacks re- 




FiG. 24.— The Situation of the Opening: made in the Skull in Case Xm, 

turned, and have been as frequent up to October, 1892, 
as they were before the operation. 



The result of these cases may be summarized as 
follows ; cured 3 ; improved 5 ; not improved 4 ; died 1. 

To these cases of my own I append short sum- 
maries of a number of cases of epilepsy which have 
been operated upon within the past few years in this 
country. 



TREPHINING FOR EPILEPSY. 55 

(1) D. B. L., m., 25, Keen, Amer. Jour. Med. Set., 
October, 1888. 

History. — Fall on right side of head, November, 1886, 
unconscious for several hours. Some days after found 
left fingers ansesthetic. Six months after had sadden at- 
tack of vertigo followed by temporary paralysis of left 
hand. These attacks continued during following year. 
Depressed fracture found over middle third right motor 
area. 

Bate of operation. — April 18th, 1888. 

Character of operation. — Trephined over depressed 
fracture. Adhesion of membranes. Spicula of bone pro- 
jecting into brain. Cyst found under the fracture. Brain 
about it altered in color and thickened, was excised. Mi- 
croscopic examination showed a chronic meningo-enceph- 
alitis of the excised brain. 

Result. — Temporary paralysis of hand. No return of 
the fits up to four months after operation. 

(2) I. G. W., m., 35, Lloyd and Deaver, Amer. Jour. 
Med. Sci., November, 1888. 

History. — Struck on head at age of 16. From age of 21 
to 35 had fits beginning with numbness and spasm in left 
hand and arm extending to left side of face. These be- 
came frequent and were followed by paresis of left hand 
and face. Consciousness not often lost in attack. 

Date of operation. — June 12th, 1888. 

Character of operation. — Trephined over junction of 
middle and lower thirds of motor area. Brain normal. 
Hand centre located by faradism and excised. 

Result. — Convulsions continued at first, but after three 
weeks ceased and had not returned at end of three months. 
Paralysis and ansesthesia in left hand permanent. 

(3) P. H., m., 39, Frank and Church, Amer. Jour. 
Med. Sci., July, 1890. 

History. — For a year had attacks beginning with pain 
and spasm in right index finger, involving rest of hand, 
wrist and arm, then loss of consciousness and general con- 



56 BRAIN SURGERT. 

vulsion. Pain in right hand and increasing paralysis with 
contracture. Right leg slightly weak. Some aphasia. 

Date of operation. — May 21st, 1889. 

Character of operation. — Trephined over left motor 
area middle and lower third. Thick cicatricial mass 
found on cortex and removed. Brain excised one and one- 
half inches in diameter, one-fourth of an inch thick. 
Mass found to be sarcoma. 

Result. — Some improvement, followed by return of fits 
in three months, at much longer intervals than before the 
operation. Paralysis much improved. 

(4) C. T., f., 39, Keen, Amer. Jour. Med. Sci., Sep- 
tember, 1891. 

History. — Fall, on left side of head. Two convulsions 
in 11 3^ears. Then frequent attacks from age of 13 to 31. 
Fits began by flexion of right hand followed by spasm of 
arm and then general convulsion. No paralysis. De- 
pressed fracture on left side over arm centre and defect in 
bone. 

Date of operation. — October 29th, 1890. 

Character of operation. — Bone and membranes taken 
away about the depression. Projecting pieces of bone 
removed. Brain beneath disorganized and depressed. 
Hand centre located by faradism and excised. 

Result. — Paralysis of the hand with ansesthesia gradu- 
ally passing off. N^o attacks at end of eight months. 

(5) G. H., m., 23, Keen, Amer. Jour. 31 ed. Sci., Sep- 
tember, 1891. 

History. — Fracture of skull. Fits two years later from 
age of 9 to 32. General convulsions. Marked depressed 
fracture. 

Date of operation. — November 21st, 1890. 

Character of operation. — Depressed fracture over lower 
parietal convolutions on right side found. Bone deficient. 
Dura absent. Brain adherent to scalp tissue. When this 
adhesion was divided the brain surface sank away from 
the skull one-third inch. No effect of faradism on brain. 



TREPHINING FOR EPILEPSY. 57 

Result. — Recovered. Two attacks after operation with- 
in two weeks. Since then none. Report six months after 
operation. 

(G) S.W., f., 27, Mills and Keen, Amer. Jour. Med. 
Sci., December, 1891. 

History. — For ten years had attacks of numbness and 
spasms beginning in the left arm and leg and frequently 
limited to them, but occasionally becoming general, usually 
without loss of consciousness. No permanent paralj^sis. 

Date of operation. — December 10th, 1890. 

Character of operation. — Trephined over right motor 
area. Bone thick. Membranes adherent. Small sarcoma 
found and removed. Also a small portion of cortex which 
was found to be normal on microscopic examination. 

Result. — Paralysis, which passed off in a few weeks. 
Attacks continued as before for six months up to report. 

(7) G. G., m., 8, Morrison, Trans. Phil. Co. Med. Soc, 
May 25th, 1892. 

History. — No traumatism. Convulsions from age of 2 
to 8, at first slight, later severe, beginning with face and 
head turning to right. 

Date of operation. — August 29th, 1891. 

Character of Operation. — Trephined over junction of 
temporal ridge and coronal suture. Dura and brain normal. 

Result. — Recovery. Fits recurred three weeks after 
operation and continued. 

(8) A. C, f., 11, Diller, Pitts. Med. Rev., November, 
1892. 

History. — Fall at six months; convulsions and left 
hemiplegia. From age of 4 to 11 convulsions beginning 
in left arm, then face, then leg with unconsciousness. 
Left hemiplegia worse in arm. Sensation diminished in 
left arm . 

Date of operation. — January 9th, 1891. 

Character of operation. — Trephined over motor area 
of arm, on right side. Fissure in bone ; cyst found un- 
der cortex contained three ounces clear fluid. Drained. 



58 BRAIN SURGERY. 

Result. — Recovery. Accumulation of fluid in the cyst 
when drain was removed. It was replaced and cyst 
drained for forty days when fluid became purulent. She 
died on forty-third day. 

(9) A. :N'., f., 31, A. B. ^hs,w,Ainer.Jour. Med. Sci., 
December, 1892. 

History. — General convulsions occurring spontane- 
ously, alternating with local spasms and always preceded 
by numbness in right hand and arm. The spasm often ex- 
tended from arm to leg. Pain and pargesthesise continu- 
ous in right arm and increasing paralysis in arm and later 
in leg. Duration two years before operation. 

Date of operation. — December 14th, 1891. 

Character of operation. — Trephined over arm area of 
left side. Bone thick, adherent to dura, veins large in pia. 

Softened pigmented brain tissue found under dura and 
partly washed awa}^. No pus found and no cj'st. 

Result. — Recovery from operation. Relief of pain and 
paraesthesia. Permanent paralysis of arm. No convul- 
sions up to seven months after operation. 

(10) W. H., m., 18, Knapp and Post, Boston Medical 
and Surgical Journcd, January 7th, 1892. 

History. — Struck over right temple in 1882. In 1883 
convulsions began and have continued until the operation, 
four or five daily. Fit begins with turning of head to the 
left, then left side of face and neck and the left arm are 
convulsed, sometimes general convulsion follows. 

Date of operation. — May 1st, 1891. 

Scar over posterior portion of second frontal convolution 
on right side. Trephined here by Dr. Post. Opening two | 
inches in diameter through the bone was made. Bone was 
very thin. Dura normal and pia oedematous and opaque. 
Brain markedly bluish. 

Result. — Recovery from the operation. Recurrence of 
the fits as before during following six months. 

(11) K. F., f., 16, Knapp and Post, Boston Medical\ 
and Surgical Journal^ January 'Tth, 1892. 



TREPHINING FOR EPILEPSY. 59' 

History. — Was struck on the head in 1885. Since then 
constant severe headache. In November, 1891, convulsions 
began, general in character, commencing with turning of 
head and eyes to the right. Depressed fracture over left 
second frontal convolution. 

Operation. — November 24th, 1890. 

Bone adherent to dura and much thickened. Dura ad- 
herent to the brain. Dura and a portion of the brain 
substance excised. 

Result. — Subsequent history during following four 
months showed a continuance of convulsions. 

(12) L. C, m., 6, Sachs and Gerster, Amer. Jour. Med. 
Sci., November, 1892. 

History. — Said to have had brain fever at age of 10 
months; at age of 5^ years first right-side convulsion, re- 
peated at interval of one week; right hemiparesis since 
first attack; athetoid and associated movements. 

Operation. — December 29th, 1890. 

Exposure by chiselling of motor area of right arm, de- 
termined by faradization. Dura tense and adherent; 
puncture ; no cyst found. 

Result. — Recovery excellent; no convulsions up to Feb- 
ruary 2d, 1891, when boy was discharged from hospital; 
after leaving hospital had one mild attack; not heard 
from since. 

(13) W. C. H., m., 20, Sachs and Gerster, I.e. 
History. — At age of 12 years was pushed back over pole 

of a wagon; supposed to have struck back of head (?) ; un- 
conscious for a few minutes, but worked as usual; one 
week later general epileptic convulsions; has petit mal, and 
above all Jacksonian epilepsy involving muscles around 
right half of mouth. Occasionally eyes are involved. No 
loss of consciousness with majority of attacks. 

Operation. — February 13th, 1891. 

Exposed centre for representation of angle of mouth 
according to Horsley ; adhesions under the button of bone ;. 
small cysts on dura; on puncture a little bloody fluid. 



60 BRAIX SURGERY. 

Faradization over dura caused contraction only of right 
angle of mouth. Large opening ; button not replaced. 

Result. — Attacks returned after operation and have not 
been diminished, and ej'es are more frequently involved. 
^o improvement. 

(14) M. K., m., 16, Sachs and Gerster, I.e. 
History. — At age of 18 months fell out of window ; since 

that time epileptic attacks at varying intervals ; has had 
tremendous doses of bromides ; ill-tempered and stupid ; 
stopped bromides ; no attacks for three weeks, then left- 
sided convulsions becoming general. 

Operation.— YobvusiTj 23d, 1891. 

Large trephine opening over motor area for arm and 
leg, right side of skull. 

Result. — Good recovery, but no cessation of attacks. 
ISTo improvement. 

(15) E. L. M., m., 30, Sachs and Gerster, I.e. 
History. — Traumatic injury to right side of head; gen- 
eral epileptic attacks. 

OjDeration.— July Slth, 1892. 

Trephining over occipital depression; adhesions over 
the depression. 

Result. — Did very well except that he developed delu- 
sions of persecution. Attacks returned within two weeks; 
alcoholic excesses. 

(10) J. D., m., 8, Sachs and Gerster, I.e. 

History. — Traumatism at seven months; six months 
previous to operation began to develop auditory and ol- 
factory aurse and then general epileptic spells ; chronic ear 
discharge; if ear ceased discharging spells became worse. 

Operation. — August 14th, 1891. 

Opening of mastoid and removing two sequestra of 
bone. 

Operation. — N'ovember ITth, 1891. 

Mastoid opened again and silver canula introduced to 
secure permanent drainage. 

Facial palsy of left side. September 10th, attack; re- 



TREPHINING FOR EPILEPSY. 61 

peated attacks of convulsion of right side until second 
operation, but none since; last report August 15th, 1892. 

Result. — Great improvement after second operation; 
no attacks up to date. 

(IT) T. C, m., 26, Sachs and Gerster, I.e. 

History. — At age of 11| years was severely kicked by a 
man over the right side of occiput ; six months later epi- 
leptic attacks which have continued nocturnally about 
every six weeks since. No hemianopsia. Marked depres- 
sion in skull ; was eight weeks without any attack ; at- 
tacks then returned. 

Operation. — November 20th, 1891. 

Trephining and chiselling over scar ; tremendous exos- 
tosis indenting underlying part of brain. 

November 22d, short spells; none while in hospital; 
discharged December 15th; has gone out West; has at- 
tacks every six weeks, but milder ; reports that his mem- 
ory is better. 

Result. — Some improvement in severity of attacks 
eight months after operation. 

(18) H. L., m., 24, Sachs and Gerster, I.e. 

History. — Six years ago fell down; thinks he struck on 
right side of occiput ; one year later first attack, right 
hand and leg convulsed. At first had attacks six times 
daily, lately three or four times in two weeks. 

Operation. — January 29th, 1892. 

Motor arm centre on left side exposed ; part of dura but 
no cortical tissue removed. 

Second operation March 8th, 1892. 

Removed arm centre as determined by electrical tests, 
with slight resulting paresis. 

Result. — Repeated attacks after both operations. No 
improvement worth mentioning. 

(19) C. D., f., 9, Sachs and Gerster, I.e. 

History. — Fell out of bed at six months, striking head 
against bare floor; at ten months a tedious illness, slow 
in developm.ent ; at age of five years began to have in- 



62 BRAIN SURGERY. 

numerable convulsions (at least fifty per day). Idiocy. 
Parents insisting on operation. 

Operation. — February 15th, 1892. 

Large trephine opening over left side of head (motor 
area). 

Result. — Attacks not quite so frequent as before. 
Slight improvement. 

(20) K. A., m., 9, Sachs and Gerster, I.e. 

History. — At age of five years had a "congestive chill" 
and spasms ; no paralysis at the time ; two or three years 
later developed Jacksonian epilepsy beginning in left hand 
without loss of consciousness ; no evidence of palsy ; boy 
feels left hand drawn up in cramp. 

Operation. — April 12th, 1892. 

Excision of hand centre in right hemisphere ; removed 
considerable tissue; hand was paretic for a few days. 

Did very well in hospital for six weeks, but as soon as 
he left hospital and ran about had severe attack with loss 
of consciousness and involuntary passage of urine. 

Result. — Some immediate improvement, but no lasting 
benefit from operation ; in later attacks right arm was also 
involved. 

(21) J. B. G., m., 31, E. D. Fisher; personal commu- 
nication.^ 

History. — Habits intemperate ; no history of syphilis; 
family history negative; a history of injury to the head 
fourteen years ago; had epileptic seizures for the past 
twelve years. Following the attacks, he became mania- 
cal, destructive, and homicidal. 

On examination, the patient was found to be well nour- 
ished, intelligent, quiet; he had a slight depression on the 
left side of the head corresponding to the hand centre of 
the motor area. 

Operation. — Maj^, 1892, atBellevue Hospital, by Dr. J. 
D. Bryant. 

^ I am indebted to Prof. Fisher for the five following cases un- 
published. 



TREPHINING FOR EPILEPSY. 63 

The skull was trephined, the opening enlarged to a 
diameter of about three inches. There was no evidence of 
internal fracture or of adhesions of the membranes. The 
dura was opened, and the hand centre located by the fara- 
dic current. The patient made a good recovery from the 
operation, although for two or three days there was a con- 
siderable elevation of temperature without evidence of any 
suppuration having occurred in the wound. 

Result. — The attacks at first increased in frequency, 
and were not changed in character ; later they decreased 
somewhat in number, but finally resumed their old fre- 
quency and nature. The patient was recommitted to the 
insane asylum on Ward's Island. 

(22) J. H., m., 22, E. D. Fisher. 

History. — Family history negative. He gave an indef- 
inite history of having received an injury on the head. 
The attacks were characterized by always commencing 
in the fingers of the left hand with a sensory aura passing 
toward the face, with resulting loss of consciousness, after 
which the convulsions became general. Patient's mental 
condition showed signs of dementia — never violent. 

Operation. — May, 1892, at Bellevue Hospital, by Dr. 
George Woolsey. 

The patient was trephined over the right arm centre, 
and a considerable portion of the skull removed. Nothing 
abnormal was found. The dura was opened, and again 
united. The hand centre was located by the faradic cur- 
rent, but was not excised. The patient made a good re- 
covery without elevation of temperature. 

Result. — The attacks, however, continued to be as fre- 
quent as before, but no longer commenced on the left side, 
being general in character. Patient's mental condition 
was unimproved. Admitted to the Ward's Island insane 
asylum, December, 1892. 

(23) A. B., m., 38, E. D. Fisher. 

History. — Negative family history. He was a moder- 
ate drinker. He gave a history of injury to the head re- 



64 BRAIN SURGERY. 

ceivecl five years previoush' from a club. About one year 
after this, he began to have sligiit attacks of an epileptic 
nature, which finally developed into complete seizures. 
Severe attacks occurred about once a month, and slight 
attacks every ds-j. His memory became somewhat im- 
paired. 

On examination of the patient a depression over the 
parietal bone was found behind the motor area. 

Operation in March, 1892, at the City Hospital, by Dr. 
J. E. Kelly. 

The patient was trephined over the site of the depres- 
sion. The inner table W8.s found depressed and pressing 
the dura, but there was no evidence of internal fracture. 
The dura was not opened. The patient made a good re- 
covery, and leaving the hospital in the summer, continued 
at work for two months. 

Result. — Up to date reports that he has had no seiz- 
ures of any kind unlesss light attacks of dizziness when 
exposed to the sun may be counted as such. 

(24) A. D., f., 20, E. D. Fisher. 

History. — Family history negative. She gave a history 
of attacks from childhood. The attacks have been almost 
continuous, and limited usually to the left side. Patient 
very much demented. The attacks at times, and just 
previous to the operation, were as frequent as one hundred 
in a day. 

Operation at the Citv Hospital in June, by Dr. J. E. 
Kelly. 

The patient was trephined over the right motor area, 
and a considerable portion of the skull removed. Nothing 
found. The hand centre was located by the faradic cur- 
rent. A small portion of this centre was excised. 

Result. — The patient died six hours after the operation, 
probably from the combined effects of her previous exces- 
sive seizures and the shock of the operation. 

(25) A. C, m., 26, E. D. Fisher. 

History. — Family history negative. The attacks were 



TREPHINING FOR EPILEPSY. 65 

very frequent, general ; patient demented and given to ex- 
cessive masturbation. He gave a history of an injury 
received from a fall when 12 years of age. On examina- 
tion, a considerable depression was found over the left 
frontal bone, at the margin of the hair. 

Operation at the City Hospital in May, by Dr. J. E. 
Kelly. 

The patient was trephined, and a considerable area over 
the frontal bone removed, but no sign of fracture nor any 
adhesion of the dura was found. 

Result. — The patient made a good recovery without 
elevation of temperature and for some weeks after the 
operation seemed much improved in this mental state; 
the attacks were very much decreased in number, and 
he ceased masturbating. Later, his condition became 
about the same as previous to the operation, and he was 
transferred to the insane asylum. 

There are many patients suffering from traumatic 
epilepsy who manifest mental symptoms either asso- 
ciated with the fits or developing in place of the fits,. 
C. F. MacDonald reports the following cases : 

(26) J. M., m., 29, MacDonald, Jour. New. and Ment. 
Dis., XIII. , August, 1886. 

A patient in the Auburn asylum, suffering from mania 
which had developed after a blow on the head with de- 
pressed fracture of the skull over the right ear, correspond- 
ing to the superior parietal lobule, was found to be the 
subject of severe general convulsions. Dr. MacDonald 
trephined, removing the bone, which was thick, roughened, 
and adherent to the dura. The patient subsequently re- 
mained entirely free from his epileptic attacks, and grad- 
ually recovered from the condition of mania, so that he 
was discharged cured seven months after the operation. 

(27) J. C, m., 24, MacDonald, Ic. 

The patient had been a chronic epileptic with periods of 
5 



66 BRAIN SURGERY. 

insanity for eight years, each attack being followed by a 
period of mania. He was found to have a depressed frac- 
ture over the right occipital region said to have occurred 
at the age of six, and he suffered from pain at this loca- 
tion. He was trephined August 25th, 1885, a button of 
bone being removed and the dura not opened. A year later 
he had had no fits at all, and though partly demented, was 
free from delusions. 

Park has recently reported two such cases, as fol- 

low^s : ' 

(28) The first was in a man of 31, who, on July 20th, 1891, 
was kicked in the left side of the head by a horse, and who 
some time later was found unconscious. He was carried 
into the house, and was aroused. He had no paralysis, 
but in three days began to act strangely and soon became 
wilful and almost violent. He developed erotic tendencies, 
and growing rapidly worse could not be kept at home. On 
July 28th, he was sent to me by Dr. Krehbiel, of York- 
shire Centre. At this time the patient was difficult to 
control and mildly maniacal. July 29th, I found a de- 
pressed area on the left side near the parietal eminence 
and a little anteriorly to it ; yet he had absolutely no motor 
symptoms. At this point there \^ as an H-shaped scar. 
Immediate operation was done under chloroform . Beneath 
the scalp I found a depression about the size of a half- 
dollar, around which I chiselled so as to entirely lift and 
remove the depressed portion. The bone was well com- 
minuted; there was a small clot beneath the bone, but 
none beneath the dura. The bone was not replaced and 
the wound was closed without drainage. He made a 
rapid recovery ; returned home in one week with his mind 
nearly clear and his disposition as it had been before the 
injury. 

(29) The second case was in a man of 45, who, when a 

1 Roswell Park : Med. News, Dec. 10th, 1892. 



TREPHINING FOR EPILEPSY. 67 

young man, had had an extensive compound fracture of 
the skull, and who for a while was under the observation 
of the late Dr. Gray, of Utica, who advised against oper- 
ation, in accordance with the practice of his day. Of late 
years the man has developed distinct epileptiform seizures 
followed by violent maniacal attacks, during which he was 
positively dangerous, so that his family lived in constant 
fear ; moreover, his disposition and temper seemed to be 
gradually changing under this stress, and it got to be a 
question whether he should submit to an operation or be 
sent to an asylum. He was placed in my hands for oper- 
ation by Dr. Putnam. This was made during October, 
1891, the depressed bone being removed, adhesions sepa- 
rated, and a portion of the scar exsected. The change in 
this case for the better has been most marked and most 
gratifying. While it is too much to say that he has not 
had a single seizure since the operation, they have been 
reduced to very mild and very rare attacks, and I believe 
it is now some months since he had anything that could 
be called a fit. In temper and disposition he is also quite 
his old self again. 

The result in these cases may be summed up as 
follows: cured 10; improved 6; not improved 11; 
died 2. 

These cases are sufficient to show that in many cases 
of epilepsy the attack begins with a clearly localizable 
spasm which extends from the part in which it begins 
to other parts in a definite order of progression. The 
majority of such cases have developed subsequently to 
an injur}". The operation of trephining often reveals 
decided pathological conditions in these cases which 
require special notice. 



68 BRAIN SURGERY. 



Pathological Changes Observed. 

In studying the cases here described the most 
interesting feature is the pathological conditions 
which have been revealed during the operation. 
These have been mentioned in connection with each 
case, but some general discussion seems warranted. 
We may consider these changes in the order in which 
they have been met with during the operation. 

I. Scalp. — Exposure of the scalp by close shaving 
very frequently reveals scars hitherto undiscovered. 
Such scars are rarely found to be tender, and, in fact, 
in no case has pressure upon the scar been followed 
by a fit. Some years since considerable notice was 
taken of a few cases in which the epilepsy was clearly 
traceable to compression of nerves in the scar tissue of 
the scalp, and it was thought to be characteristic of 
these cases that pressure upon the scar would lead to 
a fit. I have tested carefully very many patients, but 
have failed to find such tender scars upon the scalp. 
Two years ago I saw a little girl afflicted with left- 
sided convulsions, each convulsion being preceded by 
a sharp pain in the left supra-orbital nerve, and pres- 
sure upon this nerve produced sensations in the entire 
left side and the feeling of anxiety identical with that 
which usually preceded the fit. But in this case the 
division of the supra-orbital nerve, performed by Dr. 
McBurney, in the hope of removing peripheral irrita- 
tion, failed to relieve the fits. From my experience I 



I 



TREPHINING FOR EPILEPSY. 69 

consider that true reflex epilepsy from scars in the 
scalp is a very rare occurrence. 

II. Periosteum. — In a number of cases when the 
scalp has been divided and laid back a perceptible 
thickening of the periosteum over the fractured bone 
has been noticed. In one case this was so extreme 
that the periosteum could be likened to a piece of 
canton flannel. It is often found to be very vascular 
and more closely adherent to the skull than normal. I 
have never seen any apparent bony deposit beneath the 
periosteum as an evidence of repair of a broken skull. 

III. The Skull. In the cases operated upon frac- 
tures of all kinds have been met with. It is impossi- 
ble, as a rule, to determine whether the fracture in- 
volves the external table only or the internal table as 
well ; it is only by trephining that this fact can be 
settled. It is not always safe in operating for epilepsy 
to be guided by the position of a fracture unless that 
fracture coincides quite closely with the spot selected 
for trephining from the character of the fit. 

Thus, in one of my cases a depressed fracture lay 
over the left first frontal convolution, but the spot 
selected for trephining was over the middle of the pos- 
terior central convolution where the bone was normal 
(Fig. 12, page 30). When the button of bone was re- 
moved, however, a splinter of bone from the internal 
table was found penetrating the dura and brain. Thus 
the medical indication was proved to be the correct one 
to follow in spite of the fact that at the spot selected 
for trephining there was no evidence of fracture. 



70 BRAIN SURGERY. 

In many cases there is a fracture of both tables with 
decided depression of bone. Usually when the tre- 
phine opening is made a very distinct thickening of 
the skull is revealed and the density of bone is greater 
in and about these fractures. 

IV. The Dura. — In many cases the dura has been 
found roughened upon its external surface, more vas- 
cular than normal and more adherent to the bone than 
in a state of health. It is not uncommon to see white 
lines and bands running across the dura of white con- 
nective tissue, the remains of chronic inflammation. 

When the dura is divided and reflected, adhesions to 
the pia are quite commonly found. These may be in 
the form of little thread-like attachments which are 
easily broken as the dura is reflected. They may be 
very close and vascular adhesions which have to be 
dissected up with care. The dura itself is quite com- 
monly thickened and that to a very great degree, so 
that I have seen a dura three millimetres in thickness. 
Under these circumstances the thickening appears to 
have been upon the under surface of the dura. 

Not infrequently the dura forms a part of the ex- 
ternal wall of a cyst. 

V. The Pia. — When the pia is exposed in an oper- 
ation, it is almost always found to present the appear- 
ance of oedema and only after the wound has been 
opened for a few minutes and the pressure of a sponge 
or finger has been made upon the pia does the sub- 
pial fluid disappear, revealing the vascular surface of 
the brain beneath it. It would appear that in a state 



TREPHINING FOR EPILEPSY. 



71 



of health a thin layer of fluid is normally interposed 
between the cortex of the brain and its dense cover- 
ings. 

As the result of pathological changes the pia may 
be altered in its appearance. Small white dots of the 
size of the head of a pin have been seen many times, 
resembling tubercles, but not at all tubercular in 
their structure or nature. Again there may be white 




Fig. 25. — Section through Pia Mater and Cortex to show Thickening of the Pia. 
The normal thickness of the pia is indicated at yy. x^ groups of small round 
cells— fibroblasts. 1, 2, 3, indicate the chief layers of the cortex. At 2; a wedge- 
shaped mass of neuroglia tissue is seen. Such a sclerotic patch may form a focus 
of ii'ritation sufficient to cause a local spasm. 



lines or narrow bands whiter than normal pia in its 
tissue. Again the pia may be much thickened, very 
vascular, and so closely adherent to the cortex that any 
attempt to elevate it with a fine forceps fails. Under 
these circumstances it is very difficult to avoid hemor- 
rhage from these new vessels. But such hemorrhage 
can usually be checked by pressure maintained for a 



72 BRAIN SURGERY. 

few minutes evenly, or else by a light touch with the 
Paquelin cautery. The appearances of a localized 
patch of chronic meningitis with thickening are 
shown in Fig. 25, which was drawn by Dr. Van Gieson. 
He writes : " The pia mater is about three times thicker 
than in the normal condition, which is approximately 
indicated by the lines at y. The thickened pia mater 
is composed of fairly dense connective tissue, and as 
more and more fibro-blasts are developed apparently 
from the groups of small round cells at x, the mem- 
brane slowly grows thicker and thicker. Hand in 
hand with this localized growth of connective tissue 
of the pia mater, there is a disappearance or oblitera- 
tion of the blood-vessels, and in Fig. 25 it is to be 
noted that there are very few blood-vessels and there 
is no distinction between the two layers of the mem- 
brane. The effect of all this upon the structure of 
the subjacent cortex cannot be described in this case, 
for the material was not especially well prepared. 
One important change in the cortex associated with 
this condition of the pia mater is the production of a 
wedge-shaped mass of neurogliar hyperplasia. Fig. 25, 
^, which passes inward from the outer margin of the 
cortex, and is composed of spindle-shaped and branch- 
ing cells. The neuroglia cells of the barren layer are 
also slightly increased in number." 

The pia not infrequently forms the inner wall of 
a cyst, and under these circumstances it is usually so 
much congested and thickened as to be quite opaque. 
When the pia is closely adherent to the brain and is 



TREPHINING FOR EPILEPSY. 73 

very vascular, the appearance of the cortex as seen 
through it is different from that of the normal cortex. 
It is blue instead of being red, and capillary vessels, 
which in the normal cortex are seen to radiate 
toward the summit of a convolution from the two 
sulci in which the chief pial vessels lie, are no longer 
visible. 

In some cases there has been found beneath the pia 
but closely connected with it a delicate mesh- work of 
new connective tissue and vessels, making a mass re- 
sembling honeycomb, usually of the thickness of a 
centimetre. ' This connective-tissue formation is usu- 
ally full of fluid and collapses when the pia is incised. 
It is probably a relic of an old hemorrhage. 

YI. The Brain.— Is oYvasl cortex during life has 
evidence of a vascular supply most profuse and per- 
fect. Everywhere over the cortex a fine netv/ork of 
capillaries is visible, the larger capillaries running 
toward the summit of each convolution from its sides. 
It has a firm feel and a double pulsation, the pulsation 
of the heart and the pulsation on respiration. As the 
result of fractures or of meningitis the cortex may be 
changed in its appearance. It may have undergone 
compression and be indented. It may be stained with 
haematin as a remainder of an old hemorrhage. It 
may be changed in color to a darker tint and perceptibly 
hardened by new connective tissue growing into it from 

^ In an old case of right hemplegia with contractures of twenty 
years' standing the entire motor area of the left hemisphere was re- 
placed by such a honeycomb mesh of connective tissue. Secondary 
degeneration could be traced into the spinal cord. 



74 BRAIN SURGERY. 

an adherent pia. Or finally, it may be softened and 
lose its firm consistency and present a flat or depressed 
appearance very different from the normal. It may 
be actually destroyed and disintegrated by bony 
splinters projecting into it, and then it is semi-fluid in 
character or else hardened by sclerosis. 

The microscopical changes are described later by 
Dr. Van Gieson. 

It is not uncommon to find cysts in the brain. 
These may have a distinct connective-tissue wall, or 
may merely be surrounded by normal brain tissue. 
They are usually the remains of a hemorrhage or of a 
spot of softening from thrombosis or embolism of a 
small vessel. The fluid in them is usually clear serum. 
If they are divided the walls unite and the fluid does 
not collect again. If they are merely emptied the 
fluid re-forms. As we shall see in the chapter on 
tumors, cysts are not infrequent in the midst of glio- 
mata. It is possible that some of the cases of epilepsy 
in which cysts were found were really cases of be- 
ginning glioma. For the presence of a cyst can hardly 
be thought sufficient to cause irritation of the sur- 
rounding tissue, while a growing tumor might easily 
do so. 

The facts just stated in regard to the pathological 
conditions found in the brain at the time of operation 
prove conclusively that in these cases of epilepsy there 
was an organic basis for the disease, and this fact 
makes it seem very probable that in all cases of epi- 
lepsy commencing after injuries there is at some point 



TREPHINING FOR EPILEPSY. 75 

in the brain an actual pathological change. It is evi- 
dent from what has already been stated that in some 
cases this focus of disease lies immediately beneath 
the point of injury ; it is evident that in other cases it. 
lies near the cortex at some distance from the point of 
injury. It is evident that when the .part of the cortex 
involved is a part the function of w^hich is known, the 
local symptoms will indicate the situation of the focus 
of disease. It is evident, finally, that in traumatic 
epilepsy when the disease is not found under the point 
of injury, and when it does not give rise to any local 
symptoms, we have no means of knowing where it is 
in the brain, even though we are sure of its existence, 
and we have no means of treating it surgically. 

I think it may be stated, as a result of the facts 
derived from pathological studies of the conditions, 
found at operations in epilepsy, that Jacksonian and 
traumatic epilepsy are always due to a pathological 
change in the brain. 

When the pathological change is not apparent to 
the naked eye at the operation, and yet the approxi- 
mate situation of it can be determined by the local 
symptoms, Horsley proposed to determine by the ap- 
plication of faradism to the cortex the exact spot irri- 
tation of which will set up a fit like the one spontane- 
ously occurring, and then cut this spot out. This has 
been frequently done, in some cases with success, in 
others with a return of the symptoms. Several cases 
are mentioned in the collection given. The chief ob- 
jection to this method — an objection which has been 



76 BRAIN SURGERY. 

urged by numerous operators — is that excision of brain 
cortex is necessarily followed by the formation of a 
cicatrix which becomes the centre of a sclerotic patch 
in the brain. Such a patch or even a cicatrix may 
act as an irritant and give rise to localized epilepsy 
when arising from other causes. It is not unreasona- 
ble to fear that it may act as an exciting cause of a 
continuance or renewal of the fits when it is produced 
by the surgeon. Later experience rather confirms this 
fear, for even in two of Horsley's cases the fits re- 
turned in spite of the excision of the cortex. Hence 
the excision of the focus of irritation, when such a 
focus is not apparently abnormal tissue, is not to be 
recommended, since to do so is to produce a brain 
lesion comparable to that found in the cases reported. 

The exact pathological changes which take place in 
the brain after wounds have been studied by Ziegler ' 
and by Coen.^ 

Ziegler describes them as follows : 

"If a pointed instrument is thrust into the brain at 
any point a hemorrhage occurs at that point and the 
neighboring tissue is destroyed in greater or less ex- 
tent. In this way there is ^Droduced a necrotic anaemic 
or hemorrhagic focus, and the pia and sub-arachnoid 
space over this is infiltrated with blood. At the bor- 
der of the dead and living tissue there occurs a more 
or less intense inflammation in the first few days, 

1 Ziegler: "Lehrb. d. Path.Anat.," Spec. Tlieil, 1887, 5te Auflage, 
S. 358. 

^ Coen : " Ueber d. Heiliing von Sticliwunden des Geliims. " " Bei- 
trage zur Path. Anat. u. Pliys. , " ii. , p. 107, 1888. 



TREPHINING FOR EPILEPSY. 77 

which soon results in a well-marked line of demarca- 
tion between them. At the spot of inflammation, 
which extends especially along the course of the ves- 
sels which enter the brain vertically from the pia 
mater, the brain tissue becomes softened and simul- 
taneously the cell infiltration advances toward the 
necrotic focus. This latter in the course of time be- 
comes dissolved and absorbed. It may take months, 
even years, for the products of inflammation to be 
finally removed. 

" Other changes meantime go on in the adjacent tis- 
sue. The nervous tissue undergoes a degeneration in 
consequence of the change of nutritive conditions, and 
the ganglion cells and nerve fibres swell, become fatty, 
become disintegrated and destroyed. The focus of 
inflammation is thus surrounded by a zone of degen- 
eration. 

" In the first weeks the focus of inflammation consists 
of vessels, small round cells, larger corpuscles, and 
fatty and pigment granules. The last are in large 
numbers so long as the absorption of the dead tissue 
and of the extravasated blood are in progress. The 
fatty granules are also found in the zone of degener- 
ation. After weeks and months there occurs a grad- 
ual formation of connective tissue, which evidently 
commences along the vessels which penetrate the in- 
flammatory focus from the pia, and this surrounds the 
necrotic tissue or takes its place. The connective 
tissue is partly radiating in character and thick, partly 
areolar and meshlike in structure, and develops out of 



78 BRAIN SURGERY. 

the cells of the pia and of the vessels of the pia. The 
formation of connective tissue requires a long time, 
and even months or years after it has hegun it may 
be rich in round cells." 

Authorities differ as to the possibility of reproduc- 
tion of ganglion cells of the brain after destruction 
(see Coen, I. c). Coen denies that it can occur and 
holds that after a wound the new tissue found is entirely 
connective tissue containing no nerve elements. He 
says : "A true regeneration of the central nervous sys- 
tem was never observed in my experimental investi- 
gation ; the tissue which developed at the spot wounded, 
replacing the destroyed brain tissue, contained no 
newly-formed nervous elements. The ganglion cells 
are, however, able to resist the traumatic attack and 
this they do very early by indirect division of their 
nuclei. This inclination to division subsides and ceases 
when healing begins. A reproduction of brain tissue 
fails to occur in the region where brain was destroyed, 
and connective tissue fills its place which forms a scar 
in the true sense of that word" (I.e., p. 125). 

Microscopical Appearances of the Brain Tissue 

Excised, in Cases III. and II. 

By Dr. Iea Van Gibson, 

First Assistant in Histology, College of Physicians and Surgeons. 

In describing these morphological changes in the 
motor cortex which harmonize very well with the 
symptoms of epilepsy, it is of especial importance to 
preface the details of the examination with some gen- 



1 



TREPHIXIXG FOR EPILEPSY. 79 

era! remarks about the technical limitatioDS of inves- 
tigations in the finer pathology of the cortex, and the 
extreme difficulties of detecting and attaching signifi- 
cance to the very early and subtle changes in the 
cortical elements. In such a preface the investigator 
should indicate the great caution and most refined 
technique which a study of minute cortical changes 
demands; for then the reader will appreciate that 
the observer has guarded against mistaking for lesions 
entirely artificial changes, or normal structures which, 
especially in the cortex, are by no means easy to define. 
The difficulty in the way of research in cortical 
pathology is the complexity of the brain cortex ; it is 
most highly organized, and is far beyond all other 
organs and tissues in the textural delicacy of its an- 
atomical elements and complexity of their arrange- 
ment. In most of the other organs the structure 
of the parenchyma is comparatively simple, and the 
stroma is arranged in such a way that there is a con- 
trast between the two in the sections; thus in the 
kidney or liver, for example, the changes in the stroma 
or in the parenchyma attendmg a chronic inflamma- 
tion may be determined very accurately. The stroma 
is so distinct from the parenchyma and its distribution 
is so readily followed, that a very beginning of an in- 
crease in its substance may usually be easily and posi- 
tively recognized. In the same way the distinctive dis- 
tribution of the comparatively simple parenchyma cells 
permits early changes in them to be determined with 
but little difficulty. 



80 . BRAIN SURGERY. 

When we come to the brain cortex, however, the 
contrast between stroma and parenchyma which in 
other organs affords most valuable topographical aid 
is lost, and the determination of changes in either 
stroma or parenchyma is correspondingly difficult. 
For in the brain cortex the neuroglia and ganglion 
cells, corresponding respectively to the stroma and 
parenchyma of other organs, are not only more in- 
tricately constructed but are diffusely arranged. The 
neuroglia and ganglion cells are mingled together in 
a most intricate way, and are surrounded by a great 
wilderness of processes derived from both, which forms 
a very large part of what is conveniently called the 
basement substance of the gray matter. 

Thus it can be understood what a difficult matter it 
is to determine any beginning increase or proliferation 
of the neuroglia, which in ordinarily stained sections 
presents itself as multitudes of small round nuclei 
scattered all through the gray matter without any 
boundaries or limitations. This problem of the deter- 
mination of a very early increase in the neuroglia 
becomes the more baffiing because, as a rule, this 
tissue grows so slowly that the all-important criterion 
of the proliferation of cells, namely, the phases of 
karyokinesis, are difficult to find. 

The investigation of minute and early changes in 
the other intrinsic element of the cortex — the gan- 
glion cell — is rendered difficult by the presence of arte- 
facts or artificial changes occurring after death. The 
structure of the ganglion cell is so delicate and intri- 



TREPHINING FOR EPILEPSY. 81 

cate and the cortex is so slowly permeable to the 
bichromate solutions that a number of post-mortem 
changes are liable to occur in the cell or are induced by 
the action of the hardening agents. Such artificial 
changes may simulate very closely the results of dis- 
ease, and when these artificial changes are present in 
a cortex with suspected disease of the ganglion cells 
it becomes exceedingly difiicult to understand the 
lesions, or to determine in what degree the changes 
are due to disease and in what degree to artificial con- 
ditions. 

With the best of care we can recognize after all but 
the coarser and grosser lesion in the ganglion cell body, 
which is only a part of the cell. Changes in the great 
forest of processes of the cell, representing a volume 
of protoplasm tally as large if not larger than the cell 
body itself, are beyond our cognizance even with 
Golgi's methods, which seem to be of little service in 
showing minute changes in the ganglion cells. The 
aid of mitosis as an index of pathological changes in 
the ganglion cells is also absent, since the latest 
studies on this subject show that the ganglion cells 
seldom if ever proliferate. 

Thus owing either to perplexing artefacts, or to the 
inherent complexity of the cortex, its more minute 
changes seem beyond recognition at present, and when 
we do detect cortical disease processes it is only after 
they have gone on to some considerable extent beyond 
the initial stages and have become rather coarse, ex- 
tensive, or materially destructive. Since the wonder- 



82 BRAIN SURGERY. 

ful revelations of the Golgi methods, one can reason- 
ably enough conceive that changes may occur in the 
cortex which are of the greatest etiological signifi- 
cance, but so subtle that they are entirely hidden 
from our view. 

It certainly seems appropriate, therefore, to speak 
with all this detail about these peculiar difficulties in 
the way of pathological investigation of the cortex, 
for if real advances are to be made in the finer pathol- 
ogy of the cortex its difficulties of investigation should 
be appreciated, and if the lesions to be described in 
these particular cases are to be at all considered as 
underlying the phenomena of epilepsy we must ap- 
proach the problem with all possible caution. I also 
wish to show that the material placed at my disposal 
by Professor Starr has such great advantages for in- 
vestigation both in its stracture and preparation, 
that the difficulties and errors in determining early 
cortical changes are considerably reduced. 

From the fact that these minute fragments of the 
cortex were immediately transferred from the living 
body to the hardening fluid the changes in the gan- 
glion cells are especially significant, for the element of 
artificial change incident to post-mortem alteration or 
the process of hardening larger portions of the cortex, 
which frequently interferes with making positive 
statements about the minute changes in the ganglion 
cells, is more thoroughly excluded than in the material 
from an ordinary post-mortem examination. Even 
allowing for the fact that Mliller's fluid does not pre- 



TREPHINING FOR EPILEPSY. 83 

serve the ganglion cells perfectly, the damage to the 
ganglion cells, presently described, must have existed 
during life. 

Microscopic Examination of Case III. 

We may now go on with the detailed microscopical 
examination of the removed portion of the brain in 
Case III., and this comprises a description of (1) A 
rigid plate of connective tissue acting as a foreign 
body and pressing against the brain. (2) Changes in 
the pia mater. (3) Certain lesions of the cortex of 
the brain consisting of both changes in the ganglion 
cells and in the neuroglia. 

Description of the Inwardly Projecting Plate of 
Connective Tissue Indenting the Surface of the Brain. 
— The removed portion was hardened in Miiller's fluid 
plus one-sixth its volume of strong alcohol for three 
weeks. The specimen was very small, measuring 
about ten by six millimetres in diameter, and its cen- 
tral portion furnished about one hundred sections 
which were cut in series and stained double with 
hsematoxylon and eosin and by the picro-acid-fuchsin 
method. 

Sections from the centre of the specimen when re- 
constructed show that a tiny plate of very dense par- 
tially calcified connective tissue projected obliquely 
downward apparently from the dura mater against 
the surface of the brain. Here the plate is firmly 
attached to a minute localized patch of thickened pia 
mater and seems directly or indirectly to have pressed 



84 



BRAIN SURGERY, 



on the brain, for the cortex shows an abrupt little pit 
or depression (see Fig. 26) just beneath the inwardly 
projecting plate. This cortical depression correspond- 
ing to the plate is cone-shaped (with the apex pro- 
jecting inward) and has approximately an altitude of 




% 



''%&kds%p^^ 






FiG. 26.— A Section from the Centre of the Removed Portion of the Brain in Case 
III. The topographical relations of the rigid calcified spiculum of connective tissue, 
the thickened pia mater, and the depressed region of the cortex, rrx. Calcific spicu- 
lum of connective tissue, yy. 3Ioderately thickened pia mater, z. Anastomosing 
wedge-shaped group of capillaries passing into the cortex from the pia mater. 
1. 2. and 3. First, second, and third layers of the gray matter, i, Upper portion of 
the third layer. 

three and three-fourths millimetres and a base four 
to five millimetres in diameter. 

In the individual sections from the centre of the 
specimen the plate of connective tissue appears as a 
very dense, finely lamellated, partially calcified spicu- 
lum about three-fourths of a millimetre broad and 
three-fourths of a millimetre long (see Fig. 26, xx). 
At its inner extremity the spiculum has a globular 



TREPHINING FOR EPILEPSY. 85 

enlargement and the lamellae do not run parallel as in 
the outer portion, but pass in various directions mostly 
concentrically arranged about a tiny central nodule or 
core. The outer end of the spiculum is entirely free 
in all of the sections, so that it is difficult to determine 
what the spiculum is a part of or where it grew from. 
The inner end of the spiculum is attached in all direc- 
tions by many diverging fascicles of the thickened pia 
mater. 

As the sections approach the margin of the specimen 
at one side, the plate grows a trifle smaller, but still 
persists to the free edge, so that it seems probable that 
not all of the plate was removed at the operation. At 
any rate it may be said that the removed portion was 
not large enough to completely surround the plate. 
From the very dense structure of this connective tis- 
sue, and from the fact that the edge of the microtome 
knife was turned in cutting the sections, this plate 
must have formed a fairly rigid body. 

The Changes in the Pia Mater. — The pia mater not 
only at the attached end of the spiculum, but for 
some little surrounding distance (say three to four 
millimetres), shows the lesions of chronic meningitis, 
or productive or hyperplastic inflammation of the pia 
mater (Fig. 26, yy). The pia mater in the region con- 
tains an increased amount of connective tissue, which 
consists of fibro-blasts in different stages of develop- 
ment, but most of them show the more mature or final 
stages. The resultant thickening of the pia mater, 
however, is only of a moderate degree, and has not 



86 BRAIN SURGERY. 

gone on to the extent of obliterating the two layers of 
the membrane. The inner vascular layer still presents 
its normal features, although in places (see right- 
hand portion of the pia mater in Fig. 26) the vessels 
appear to be somewhat diminished in number. 

The meshes of the inner layer of the pia mater in 
the depressed region of the cortex are distended and 
form a network (Fig. 26, rv) filled with extravasated 
red blood cells. This extravasation of blood as well 
as some minute hemorrhages in the gray matter seem 
to be of artificial origin, and are very likely referable 
to the manipulation in the removal of the specimen at 
the operation. 

TJie Lesions of the Cortex. — The lesions of the cor- 
tex in this case might easily escape detection without 
the most careful scrutiny and technique. There are 
hardly any gross changes in the cortex which would 
attract attention with the low power, and it is only 
with the oil immersion lens that slight changes in the 
neuroglia cells and scattered damaged ganglion cells 
become fully apparent. These cortical changes are 
very minute and not at all striking, and yet they are 
none the less definite and significant. 

The Ganglion Cells. — The ganglion cells are affected 
by a series of degenerative changes which in their 
most advanced stages result in an almost complete 
dissolution of the cell, and yet this degeneration is not 
extensive enough to involve the cells so universally as 
to interfere with their topographical distribution. 
Besides this, most of the damaged cells are in the 



TREPHINING FOR EPILEPSY. 



87 



earlier stages of the degeneration so that they still 
retain their form and appropriate position. Thus in 
reconnoitering the sections with the lower powers the 
ganglion cells do not appear deficient in number ; they 
are properly arranged and their several layers are 
perfectly distinct. The following description applies 
to all of the ganglion cells excepting the layer of small 




Fig. 27. — Various Phases of the Earlier Stages of the Degeneration of the 
Ganglion Cells, The thin lines enclosing the cells at and to represent the- pericel- 
lular spaces ; the cells x and y show the earliest stages, w and s later stages, 
and iT shows the ultimate destruction of the whole of the ganglion cell body, 
leaving nothing but the nucleus lying in an empty space. 



pyramids. For especial reasons this layer will be dealt 
with separately later on. 

It will be convenient to describe the appearances of 
the nucleus and protoplasm of the degenerated gan- 
glion cells separately. The prevailing form of nuclei 
shows a distinct peripheral zone, indicating the nuclear 
membrane ; just inside of the nuclear membrane is a 
narrow clear zone surrounding the chromatic elements 



88 BRAIN SURGERY. 

of the nucleus, appearing in the form of a skein of 
finely dotted interlacing filaments which show the 
usual thickened appearances at the nodal points and 
surround unstained interstices. The nucleolus is seen 
in most of these skein-like nuclei, and both the nucle- 
olus and the character of the skein show no variations 
relating to the different degrees of dissolution of the 
ganglion cells. In both the early and ultimate stages 
of the degeneration the form cf nucleus as shown in 
Figs. 27, 28, and 29 remains about the same in all of 
the cells. 

This particular form of nucleus in some of the cells 
is a trifle suggestive of one of the initial stages of 
karyokinesis, but none of the other stages of mitosis 
are present, so that this appearance of the nucleus 
must be regarded as an indication of retrogressive 
changes. There are no indications of mitosis in any 
of the ganglion cells, and this agrees with one of the 
latest papers on the ganglion cell reproduction by 
Fiirstner and Knoblauch {Arcliiv filr Psych. , XXIII. , 
135). 

Some different appearances of the nucleus are shown 
in Fig. 27, in the cells t', lu, and y. The nucleus of 
the cell tu has its chromatic elements resolved into a 
number (some twenty to twenty-five in optical section) 
of larger and smaller globules or discs resembling very 
much the ordinary nucleolus. In the cells ^ and v the 
chromatic substance is collected into thickened strands 
or large lump-like masses. 

The protoplasm of the cells shows a series of changes 



TREPHINING FOR EPILEPSY. 89 

which finally result in an entire disappearance of the 
cell body — for a very complete series of intermediate 
stages can he observed between the slightly and most 
completely degenerated cells. The earlier stages of 
degeneration consist in larger and smaller solutions of 
the substance of the cell so that hollow-looking vesi- 
cles appear in the cell body. Such cells are shown in 
Fig. 27, X and y, Fig. 28, x, and Fig. 29, a. The cell 
X in Fig. 27 also shows a ragged or roughened profile 




Fig. 28. —Shows Other Phases of the Degeneration of the Ganglion Cells. The 
cell X shows liquefied vesicles at the junction of two processes with the cell body 
and three small round cells crowded in the pericellular space ; the cell y shows a 
series of liquefying seams or channels. 



at one margin of the cell body. These vesicles fre- 
quently appear at the junction of one of the larger 
processes with the cell body as in Fig. 28, x, Fig. 29, 
a, or in the process itself some little distance from the 
cell (Fig. 29, a). 

In a somewhat later stage, by the increase of these 
vesicles, and by their apparent coalescence, the cell 
body becomes more reduced in volume, deformed in 
its contours, and loses its processes. Besides the vesi- 
cles, liquefied seams and communicating channels also 



90 



BRAIN SURGERY. 



appear and contribute their share toward the destruc- 
tion of the cells. 

A very beautiful example of these channels or seams 
is shown in Fig. 28, y. This is one of the very large 
ganglion cells peculiar to the deeper layers of the 
motor zone and it was situated on the extreme edge of 
the section, so that it must have been immediately 
fixed by the hardening solution, and may be regarded 




Fig. 



-Other Variations of the Phases of Degeneration of the Ganglion Cells 
described in Figs. 27 and 28. 



therefore as showing very nearly the same condition 
possessed during life. 

The cell c, Fig. 29, also shows a somewhat similar 
condition and illustrates how the apical process is 
being separated from the cell; the protoplasm sur- 
rounds the nucleus as a deformed or deficient mass 
such as is shown in Fig. 27, w and s, and Fig. 29, h. 

In some of the degenerated cells the protoplasm at 
the bounding surface becomes frayed out, or loosened 
from the cell body in little granular islands or cord- 



TREPHINING FOR EPILEPSY. 91 

like masses, while the remainder of the cell body may 
be comparatively intact. This is represented in Fig. 
27, u, and in Fig. 29, a. The cell a, Fig. 29, is again 
one of the very large cells in the deeper layers and 
was situated just at the free edge of the section so 
that it must have been fixed in a perfectly natural 
condition. 

In still others of the ganglion cells the protoplasm 
is studded with irregularly distributed shining dots. 
In most of the cells affected in this way, and they are 
comparatively few in number, these dots seem akin to 
and react like hyaline material, and their appearance 
is shown in Fig. 27, v, y. These hyaline dots are 
present in both the slightly and severely damaged 
cells (Fig. 29, e). 

In focussing on the surface of the cell z in Fig. 27, 
some larger lump-like hyaline masses were noted. 

Thus far, to the rather restricted extent that we are 
able to recognize them, the beginning and most limited 
changes in the ganglion cell body have been described. 
There were larger and smaller vesicular or channel- 
like solutions of the substance of the cell body, and a 
tendency toward disappearance or separation of the 
processes. 

We may now go on with the consideration of the 
final and more grossly destructive phases of the gan- 
glion cell degeneration. Some of these cells undergo- 
ing the later stages of the degeneration are reduced 
to a mere shell or skeleton of the former cell ; the out- 
line of the cell is preserved, but the cell is hollow ; the 



92 BRAIN SURGERY. 

bounding surfaces are intact, and enclose the nucleus 
lying in an empty space or surrounded by a few shreds 
or granules of the former i^rotoplasm (see Fig. 27, A;, 
and Fig. 29,/). This condition seems to result from 
the extension and coalescence of the liquefactive seams 
and vesicles already described, and it is easy to trace 
the extension of the changes in the cell y, Fig. 28, to 
the cell cZ, Fig. 29. 

These skeleton cells, when followed still farther in 
their degenerative course, show gradual dissolution 
and disappearance of the bounding shell, so that ulti- 
mately nothing remains of the cell but the nucleus, 
which lies bereft of protoplasm in the space once occu- 
pied by the ganglion cell (Fig. 27, k; Fig. 29,/). 

Another way in which the ganglion cell ultimately 
becomes reduced to a mere nucleus is not so much by 
a solution of the protoplasm internally, as just de- 
scribed, but by a direct abstraction of portions of the 
external zones of the cell body. There is at first a 
slightly roughened surface of the cell, at some portion 
of its extent, with a fraying out of shreds and most 
minute fragments of protoi3lasm into the pericellular 
space. Then there is a tendency toward a distinct 
sequestration of a portion of the protoplasm (Fig. 29, 
6, e), so that the cell body grows smaller and smaller 
as the solution of its substance proceeds from without 
inward. Thus the cell becomes deformed and atro- 
phied ; it loses its processes, and the pericellular space 
sometimes contains minute fragments of the loosened 
protoplasm (Fig. 29, e). Ultimately the cell becomes 



\ 



TREPHINING FOR EPILEPSY. 93 

reduced to a naked nucleus lying in the pericellular 
space, as just described (Fig. 27, k; Fig. 29,/). 

Very often this wasting away of the cell body from 
without inward is also combined with the liquefactive 
vesicles and channels or other forms of degeneration 
in the interior of the cell body (Fig. 29, a). 

The ultimate fate of these nuclei bereft of the gan- 
glion cell body cannot be determined positively, but 
some of them become destroyed. The nuclear mem- 
brane and chromatin skin become disintegrated and 
finally nothing is left but some fragments of the 
chromatin elements, surrounded by a complete or in- 
complete ring, which still take up the color of the 
nuclear dyes. 

The description of the changes in the ganglion cells 
refers to the deeper layer of cells, and especially to the 
very large ganglion cells of the fourth layer, charac- 
teristic of the motor zone. The very large size of the 
cells renders the detection of the degenerative changes 
much more positive than in the other small cells. To 
be more certain of the ante-mortem origin of these 
lesions in the cells as many as possible were selected 
for study in glycerin mounts at the extreme edge of 
the specimen where they must have been immediately 
fixed in a natural condition. The spaces about these 
cells are small, and altogether the element of artificial 
changes may be more thoroughly excluded from them 
than in the much smaller cells. 

One of the most striking features of this degenera- 
tion of the ganglion cells is the extensive involvement 



94 BRAIX SURGERY. 

of these very large cells of the fourth layer. It may 
be that this feature is so evident, from the fact that 
the degenerative changes are so much easier to recog- 
nize in these cells, but it would appear as if they were 
especially selected by the degeneration. At any rate 
very few of the large cells are left intact, they show 
quite universally one phase or another of the degen- 
erative changes. In cutting out the fragment at the 
operation, the knife seems to have sliced it off just at 
or below this layer of cells, so that very many of them 
lie right at the edge of the sections. Many of the 
smaller cells of the third and fourth layers, however, 
show precisely similar degenerative changes. There 
are many normal ganglion cells in deeper layers, and 
the degeneration affects apparently, excepting the 
very large cells, only isolated or small groups of cells 
here and there, and yet the aggregate number of the 
damaged cells muot be very large. 

Still another feature about the ganglion cells re- 
mains to be described. This consists in the accumu- 
lation of clusters of from one to four or five small 
round cells crowded together in the pericellular spaces 
of both the diseased and normal cells. These cells 
have a very thin envelojDe of j)rotoplasm and they are 
generally situated at the base of the cell. These cells 
are not infrequently found in brains with normal 
ganglion cells, and which have given no symptoms, 
and in the present case I am unable to interpret their 
meaning or determine what kind of cells they are. 

We may now describe the layer of small pyramids 



TREPHINING FOR EPILEPSY. 95 

which has been held apart from the deeper layers, 
because the element of artificial changes cannot be as 
positively excluded. The small pyramids are quite 
universally altered, and but a very small number of 
natural cells are found in the sections. The nucleus 
surrounded by little if any protoplasm lies in a rather 
large empty pericellular space, as shown in the right- 
hand portion of Fig. 31. But just such a picture of 
the small pyramids as this is generally found in any 
cortex unless prepared by especial methods, and is 
generally to be regarded as largely of an artificial 
character. The small pyramids are especially prone 
to artificial changes, apparently from their very small 
size which seems to render them correspondingly liable 
to shrinkage. Artificial changes in this case, how- 
ever, must be considered reduced to a minimum, and 
these alterations in the small pyramids in this case 
are not present in sections of the motor cortex of an 
electrically executed criminal, prepared in the same 
way and studied along with this case as normal con- 
trol sections. So that while there may be reason in 
this instance for regarding these changes in the small 
pyramids as the results of actual disease, there is still 
doubt about it, and I prefer to disregard or exclude the 
small pyramids entirely from the larger, deeper cells 
where the lesions are definite, positive, and significant. 
The Pericellular Spaces. — There is very little to say 
about the lymph spaces of the ganglion cells. They 
show no striking changes and are not enlarged. The 
space about the deeper cells fits fairly closely, and the 



96 BRAIN SURGERY. 

relations of the cells and spaces is especially well pre- 
served. The spaces of many of the degenerated cells 
appear very large, but this effect is produced by the 
atrophy of the enclosed cell. 

The Basement Substance of the cortex, consisting, 
as it does, largely of the processes of the ganglion cells, 
must contain changes corresponding to the degene- 
rated and destroyed ganglion cells, but such a lesion 
is entirely too subtle to be recognized at present even 
with Golgi's methods. Some of the larger isolated 
processes in the basement substance show with the 
very highest powers an irregularity of outline of the 
process. These processes show minute nickings or a 
jagged outline of the edges. In one such process a 
clear vesicle was found like those described in the 
bodies of the degenerating ganglion cells (Fig. 29, a). 

As regards the distribution of these ganglion cell 
changes^ they are not especially concentrated about 
the region of the foreign body, but are scattered all 
through the sections, even to the lateral boundaries. 

There is no positive support for making statements 
about the duration of the ganglion cells degeneration, 
but the impression is conveyed that the process is an 
exceedingly slow and gradual one. The cells do not 
showv the swollen and other appearances of rapid de- 
generation such as are seen in the acute processes of 
the spinal cord. It seems probable that these dam- 
aged cortical cells may persist for a long time in the 
earliest stages of degeneration before advancing to 
the later or final stages. 



TREPHINING FOR EPILEPSY. 97 

The Changes in the Neuroglia. — There is a limited 
and very early stage of hyperplasia of the neuroglia 
tissue. This statement, however, can be better relied 
upon if the excessive difficulties attending the de- 
tection of this stage of a slowly growing neuroglia 
hyperplasia are indicated. The neuroglia cells appear- 
ing in ordinarily stained sections as small round cells 
are very profusely scattered throughout all of the corti- 
cal layers except in the barren layers, and their true 
form is only apparent by Golgi's methods. Then 
again, these cells are irregularly distributed, and vary 
somewhat in different cortical regions. In some lay- 
ers they are very thickly aggregated together, and in 
other layers more sparsely arranged. Thus in this 
diffusely arranged tissue, without contrast to the 
surrounding tissues, in determining a slight increase 
of newly formed neuroglia cells which look exactly like 
their surrounding progenitors we often have an insol- 
uble problem. When the young neuroglia cells have 
become more mature, and possess a larger cell body 
with beginning branches, a new difficulty arises in 
their identification, for frequently they cannot be dis- 
tinguished from the surrounding ganglion cells of the 
same size. So the earlier diffuse increase of neuroglia 
is unfortunately liable to escape recognition until the 
process has become fairly extensively developed. 

Notwithstanding these difficulties there are a few 
places in the sections which show quite distinctly 
clusters of an increased number of a very young and 
seemingly proliferated neuroglia cells. These are most 



■m 



98 BRAIN SURGERY. 

distinctly seen in the layer of small pyramids. In a 
few places in the layer there are groups of small round 
cells, which, although they are not sharply circum- 
scribed, are still so closely aggregated that they stand 
out more clearly than the remainder of the rather 
sparsely distributed neuroglia cells of this layer (see 
Fig. 30). The contrast of the barren layer is also an 
aid in distinguishing these cell groups. These cells 
are often arranged in groups of twos or ill -defined 



r^* 



^ 



Fig. 30.— a Group of Young ]Seuroglia Cells Situated in the Layer of Small 
Pyramids 



strings of four to six in number. In two cells only 
were positive evidences of mitosis discovered, and these 
are shown in Fig. 30, a, and more highly magnified in 
Fig. 32, h. 

In the deeper layers there are some similar groups 
of increased neuroglia cells, but they are much less 
clearly defined. Thus the production of neuroglia in 
the deeper layers is hidden from view, because the 
normal neuroglia cells are so thickly aggregated that 



TREPHINING FOR EPILEPSY. 99 

the newly formed cells cannot be distinguished from 
them. In one single instance in all of the sections, a 
cluster of neuroglia cells on the edge of the specimen, 
in the deeper layers, was quite circumscribed from the 
surrounding cells and grouped differently and seemed 
to be a cluster of proliferated young neuroglia cells. 
These young neuroglia cells at first seem to be indif- 
ferent cells. They have a thin, spherical envelope of 








Fig. 31.— a Group of more Mature Neuroglia Cells in the Layer of Small 
Pyramids. 

protoplasm, which at first appears to have no pro- 
cesses. 

At a later stage of development the protoplasm in- 
creases in volume and they lengthen out into spindle 
or oval -shaped masses and send out branching pro- 
cesses. Groups of these more mature neuroglia cells 
were also found in the sections, and they could be 
identified most clearly in the layer of small pyramids, 
because here there was no danger of mistaking them 
for small ganglion cells, for the small pyramids were 
so universally and thoroughly shrunken (see Fig. 31). 



100 



BRAIN SURGERY. 



If there are other groups of these more mature neu- 
rogha cells in the deeper layers, they cannot be dis- 
tinguished plainly because of their close resemblance 
to the small or polymorphous ganglion cells. 

Fig. 30 at a shows this difficulty of distinguish- 
ing newly formed neuroglia cells from ganglion cells. 
These two sets of cells seem to be neuroglia cells ; they 
have large, glassy cell bodies, and suggest a phase of 
cell division. Both of these two groups of neuroglia 
cells were found among the larger ganglion cells of 
the fourth layer, and are significant in evidencing an 
overgrowth of neuroglia in this important layer of 
the motor zone. Finally, in a single instance, a very 
large mature branching neuroglia cell was found in 




Fig. 32. —Isolated Neuroglia Cells from Different Layers of the Cortex. A, Two 
neuroglia cells from the deeper layers, apparently undergoing proliferation. 5, 
The cells indicated at a in Fig. 30 more highly magnified, which show Karyo- 
kinetic figures. C, A large spider cell lying alongside of the nucleus of a com- 
pletely degenerated ganglion cell. 



the deeper layers, as shown at Fig. 32, c. Lying 
alongside of this large spider cell is the remains of the 
nucleus of a degenerated ganglion which may, per- 
haps, convey a suggestion as to the destiny of the pre- 
viously described small round cells crowding the spaces 
of the ganglion cell, but there is no real evidence to 
connect these two sets of cells together. 



TREPHINING FOR EPILEPSY. 101 

There is then an increase of neuroglia in these sec- 
tions, and it is of a very early and limited stage of 
development, and yet the impression is conveyed that 
only a portion of this growth is apparent in certain 
favorable situations, as in the narrow layer of the 
small pyramids. Still there are several indications of 
neurogliar growth in the deeper layers, as for exam- 
ple in Fig. 32, inviting the belief that the process is 
not limited to the region where it may be recognized 
most easily, but is a diffuse growth and involves the 
layers beneath the small pyramids, but possibly to a 
less extent. 

The neurogliar hyperplasia is irregularly distrib- 
uted throughout all of the sections, even at a distance 
from the foreign body, and often occurs in snots or 
patches. Most of the sections of the depressed region 
of the cortex show a slight concentration ot the neu- 
rogliar growth as young, small, round cells or more 
mature spindle-shaped cells scattered about among the 
lesser pyramids. 

This growth of the neuroglia, like the degeneration 
of the ganglion cells, seems to take place exceedingly 
slowly. 

The blood-vessels of the cortex are normal in struc- 
ture, but in places they are not properly arranged. In 
places anastomosing networks of capillaries penetrate 
the cortex from the pia mater and, accompanied by 
and surrounded by more or less neurogliar increase, 
appear as wedge-shaped areas in the section. This is 
shown schematically at Z, Fig. 26. 



102 BRAIN SURGERY. 

Microscopical Examination of Case II. 

In this case there is a development of rather a large 
mass of connective tissue which has altered very 
materially the structure and topography of the con- 
volutions which it has grown into. In this way the 
gray matter at the seat of the operation has been 
irregularly replaced by connective tissue, and has been 
rather largely converted into neurogliar tissue. 

The removed portion was a flattened disc and meas- 
ured about two cm. in diameter and was from five to 
seven mm. thick; it was hardened in strong alcohol 
and the celloidin sections were stained in the same 
way as in the preceding case. 

The specimen consists of two layers, an outer layer 
of connective tissue and beneath it a layer of damaged 
cortex. At one side of the specimen a new layer 
makes its appearance, from the fact that a bit of the 
scalp is adherent to the specimen and has been re- 
moved with it. Throughout the remaining extent of 
the specimen the scalp is absent and the connective- 
tissue mass referred to is the outermost layer. Sec- 
tions from the region of the specimen where the scalp 
is attached show the appearances in Fig. 33. The 
scalp (a) with its clusters of fat cells and obliquely cut 
hair follicles covers and partly surrounds a bit of 
damaged cortex (c) . The scalp shows atrophic changes 
of a moderate degree and the attachment to the brain 
is rather a loose one. The brain, in this particular 
part of the specimen at any rate, simply lies against 



TREPHINING FOR EPILEPSY. 



103 



the scalp rather than being attached to it, and there 
are no blood-vessels passing from the one to the other. 
A tongue-like projection of rather dense connective 
tissue (Fig. 33, h) passes inward from the scalp at 
one place — just at the edge of the specimen — and 
tends to partially surround the degenerated fragment 
of the cortex. This tongue-like mass blends with, or 
is perhaps a portion of, the extensive lamina of connec- 






-C.. ~^-0^ 



CL. 
















Fig. 



-A Section through the Scalp in Case II., and Degenerated Cortex be- 
neath showing their Loose Attachment. 



five tissue forming the upper layer throughout the 
rest of the specimen (see Fig. 34). 

The bit of cortex lying underneath the scalp is very 
extensively changed. The ganglion cells are severely 
degenerated, many of them are reduced to mere hollow 
shells or skeletons surrounding the nuclei, and many 
others must have disappeared entirely. There is also 
a very perceptible increase in the size and number 
of the neuroglia cells. Both of these changes have 
reached such advanced stages that there is no difficulty 
attending their positive recognition. 



104 BRAIN SURGERY. 

Sections through the centre of the specimen show in 
a general way masses of dense connective tissue which 
encroach upon and cause material changes in the con- 
volutions, as depicted in Fig. 34. Such a section from 
the centre of the specimen shows three convolutions, 
A, B, and C, two of which are involved by the con- 
nective-tissue growth, while a third, A, has escaped 
this encroachment. 

The convolution A, although uninvolved by the 
connective-tissue growth and retaining its proper form 
and volume, is yet considerably changed. The gan- 
glion cells are fairly extensively affected by various 
phases of a series of degenerative changes. Very 
many of the cells show the earlier and less well- 
pronounced stages of the degeneration, while a lesser 
number show the more extensive changes in the cell 
body tending toward complete disintegration of the 
cell as described in the previous case. Altogether 
the degeneration of the ganglion cells in this convolu- 
tion is so well marked as to do away with the difficul- 
ties attending the recognition of the very early stages 
of the same process. 

The neuroglia of the gray matter does not seem to 
be increased to any appreciable extent, but the white 
matter (x) is quite extensively involved by a growth 
of spindle-shaped and branching neuroglia cells. At 
the apex of the convolution this neurogliar increase 
extends a little distance into or seems to follow the 
passage of the nerve fibres into the gray matter. 

In the convolution B the dense growth of connec- 



TREPHINING FOR EPILEPSY. 



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106 BEAIN SUKGERY. 

tive tissue appears, hollowing out the apex of the 
convolution, and in many places at its junction with 
the gray matter fashions the latter into curious little 
islands or tubular plugs (Fig. 31, Z, Z^ Z) often more 
or less surrounded by con nee t It e tissue. The brain 
tissue of the convolution B shows a tendency to be- 
come converted into neuroglia tissue, especially in the 
regions Z^ Z, Z, where it consists entirely of neuroglia 
cells with their branching and tangled processes. In 
the other portions of the convolution there are quite a 
few degenerated ganglion cells scattered about among 
the proliferating or much -increased neurogiiar ele- 
ments, so that the rest of the entire convolution is ex- 
tensively damaged, and the gray matter cannot be 
distinguished from the white matter except by the 
presence of the degenerated ganglion cells. 

In the convolution C there is a still greater pro- 
duction of connective tissue and a corresponding dim- 
inution in the substance of the cortex. At (h) the 
plane of the section has cut the insulated masses of 
the cortex lengthwise, so that they appear as rather 
short convoluted cylinders. Some of these cylinders 
or plugs persist, completely isolated in the dense con- 
nective tissue, as little islands of neurogiiar tissue 
(see Fig. 3 J:, iv). 

When the process of insulation of clustered or iso- 
lated masses of the cortex is examined with more 
detail in a section at the junction of the connective- 
tissue masses with the cortex, the features shown in 
Fig. 35 (taken from the convolution B) are presented. 



TREPHINING FOR EPILEPSY. 



107 



In snch a section four tolerably distinct layers may 
be recognized. Proceeding from without inward 
toward the brain, there is at first the very thick ex- 
tensive layer of dense connective which has already 
been topographically studied in the preceding para- 
graph. The first layer is apparent ui Fig. 35 at a. 




Fig. 35.— (From the convolution E) shows a more detailed view of the for- 
mation of islands of neuroglia tissue from the changed cortex at the junction 
with the connective-tissue masses, and consists of four layers, viz. : a. Layer of 
dense connective tissue; 66&, vascular layer; ddd and c, layer of clustered 
neuroglia islands ; ee, the compact cortex largely converted into neuroglia. 



It is composed of ordinary connective tissue, rather 
densely arranged, with its fibre bundles interlacing 
and running in various directions, and contains very 
few blood-vessels. The second and next layer is a 
vascular zone and lies immediately beneath the pre- 
ceding layer. It is composed of a congeries of thin- 



il 



108 BRAIN SURGERY. 

walled vessels, which give the impression that many 
of them are newly formed. This second layer is shown 
in Fig. 35 at hhh and c. Still proceeding inward, the 
third layer, ddd, is the one which consists of the clus- 
tered or discrete islands and plugs of neurogliar tissue. 
Finally, the fourth and last layer is the compact sub- 
stance of the brain, ee, which has its neuroglia much 
increased and its ganglion cells quite thoroughly re- 
placed or degenerated. In fact, this fourth layer rep- 
resents brain cortex largely converted into neurogliar 
tissue. 

Now the third layer of the insular masses seems in 
great part, if not entirel}', to owe its origin to the 
agency of the newly formed vessels of the second or 
vascular layer. These thin-walled vessels appear to 
pass into the compact brain substance, and by anas- 
tomosing with each other and by sending off secondary 
offshoots surround little island- like masses of the 
brain, which has already been largely converted into 
neurogliar tissue. In Fig. 35, at/, the early stages of 
such a process can be observed. Here are delicately 
walled small vessels or capillaries growing into the 
brain, and by the course they pursue and by their ten- 
dency to unite with each other they exclude little 
island-like masses of the cortex. 

Thus the layer of insular neurogliar masses seems 
to be formed from the compact brain by a peculiar 
segregating action of newly formed blood-vessels. It 
is further to be noted that following quite universally 
the layer of insular neurogliar masses, there is always 



TREPHINING FOR EPILEPSY. 



109 



this vascular zone, intimately associated with them, 
and it lies between the dense masses of connective 
tissue and the islands. So the capillaries seem to de- 
termine the separation of neurogliar masses from the 
changed solid cortex and mould them into tiny islands 
or short cylinders (Fig. 36). In Fig. 36 (taken from 




Fig. 36. — The Relation of the Capillaries to the Insular Masses of Neuroglia. 
yij is a collapsed capillary ; xx indicates a solid protoplasmic offshoot of a cap- 
illary, which is destined to become a new vessel and subdivide one of the insular 
masses into two portions. 



the region C, in Fig. 35) a still more detailed exposi- 
tion of this relation of the vessels to the neurogliar 
islands is presented. Here the capillaries, one of them 
collapsed at yy, are seen surrounding the plugs and 
islands. But at xx is shown a stage of subdivision of 
one of these islands by a solid protoplasmic offshoot 
of a capillary destined to become hollowed out into a 
new blood-vessel. Care was taken not to confound 
this solid protoplasmic process with a collapsed capil- 



110 



BRAIN SURGERY. 



lary, and it can be observed how it would divide the 
mass in two nearly equal parts by uniting with the 
opposite capillary. 

Some of these masses of neuroglia persist as isolated 
little islands even in the midst of dense connective 
tissue, as shown in Fig. 37. In such instances, con- 




- ~-i 



Fi&. 37. —The Minute Structure of these Neurogliar Islands and their Persis- 
tence in the midst of Dense Connective Tissue. At a the filaments of the neu- 
roglia cells are cut transversely, and at 6 two tongue-like extensions of a neu- 
rogliar island fill up two inter-fibrillary spaces. 



nective- tissue fasciculi have apparently followed the 
course of the capillaries and have grown about the 
neurogliar islands. Fig. 37 also shows very faithfully 
the minute structure of these islands. They consist of 
rather large, glassy neuroglia cells completely envel- 
oped by their own tangled and matted process. In 
the mass indicated at a the filamentous processes are 



TREPHINING FOR EPILEPSY. Ill 

€11 1 vertically, and at h two tongue-like processes of 
neuroglia pass beneath connective-tissue fascicles and 
fill up two inter-fibrillary spaces. The vessel, c, has a 
thickened or hyaline wall. 

Finally, it is to be noted that the cortex for some 
little distance surrounding the connective-tissue growth 
is considerably damaged by a degeneration of the 
ganglion cells and an overgrowth of neuroglia. 

Remarks. — It is exceedingly difficult to follow out 
the connected history of this process without having 
the opportunity to study the whole of the involved 
territory of the brain. The rather limited material 
examined in the removed specimen fails to show the 
lateral border zones of the process or the relations of 
the brain membranes, and in general the whole topo- 
graphical distribution of the lesion. Thus there is 
no distinct clew to the origin of the process or to the 
formation of the cyst discovered at the operation. 
Still it may be said that this dense mass of connective 
tissue seems to have grown down rather slowly, ap- 
parently from the membranes of the brain, and by 
disintegrating portions of the brain beneath has con- 
tributed to the formation of the cyst, for there is in 
places distinct evidence of disintegration of the cortex 
beneath the overgrowth of connective tissue. The 
peculiar segregation of the little islands of the neu- 
rogliar cortex is seen in meningoceles of very young 
children, but whether any congenital deflection is 
behind the process in this case is a question which 
may be merely presented, but not commented upon. 



112 BRAIN SURGERY. 

Results of Trephining in Epilepsy. 

When the result in these cases is reviewed, it is 
evident that in the majority there has been a failure 
to permanently cure epilepsy by operative interference. 
When we raise the question why the operation has 
failed, the obvious reply is offered that the original 
condition which gave rise to the fits has not been re- 
moved. This is evident from a study of the patholog- 
ical changes already enumerated. It is, of course, 
quite possible to elevate depressed bone, to remove al 
cyst, or to take away any mass of connective tissue or 
tumor which compresses the brain. But on the other] 
hand it is useless to break up adhesions between dura 
and pia or between pia and brain, because they will] 
inevitably re-form immediately after the operation. 
Nor is it possible to accomplish anything when the piaj 
and cortex are together affected by such connective-! 
tissue changes as have been described. Fine trabe- 
culse of connective tissue entering the cortex from the I 
pia and forming a dense scar tissue in and about the] 
motor cells give rise to an irritation which can only 
be removed by the excision of the mass. But excision] 
of such a mass together v/ith the brain, or excision oi 
a softened mass of brain, is inevitably followed by a| 
formation of a connective-tissue cicatrix which in tun 
will act as an irritant. 

Thus the pathological conditions met with in these! 
cases are frequently such as to make any possibility ofj 
a relief by an operation out of the question. 



TREPHINING FOR EPILEPSY. 113 

I think the fact that the underlying organic brain 
disease producing the epilepsy cannot always be erad- 
icated by an operation fully explains the failures which 
have been recorded by so many observers. 

The question then arises, Shall we continue to tre- 
phine any cases of traumatic or localized epilepsy? 
Judging by general results which are unfavorable, we 
should be inclined to stop. But when it is taken into 
consideration that in no case is it possible without an 
operation to determine the exact pathological condi- 
tion present, and that a certain proportion of the path- 
ological conditions are removable, it is evident that an 
operation if not attended with danger may be reason- 
ably undertaken. Some patients have undoubtedly 
been cured. 

The statement should be made to the patient : You 
have a brain disease; that disease is causing fits; that 
disease may be curable by operation ; we cannot tell 
whether it is curable until we operate; we cannot 
promise that the operation will in any way benefit ; a 
majority of chances are against cure, but it is the only 
method of treatment which affords any hope what- 
ever, and it is a method which is fairly safe. 



CHAPTEE III. 

TREPHINING FOR IMBECILITY DUE TO MICRO- 
CEPHALUS. 

Clinical Types of Microcephalic Children : (1) Paralytic Cases; (2) 
Imbeciles ; (3) Cases of Sensory Defect. The Occurrence of 
Epilepsy in these Children. The Pathology of these Clinical 
Types. The Operation of Craniotomy and its Results. Table of 
Cases. Report of Personal Cases. Conclusions. 

The medical treatment of imbecility occurring in 
childhood is so hopeless that the recent proposal to 
invoke the aid of surgery in these cases has excited 
much interest. The public, as well as the medical 
profession, is anxious to learn how far success may be 
looked for from craniotomy, and to obtain facts upon 
which to decide the question of operative treatment. 
To neurologists the subject is of immediate impor- 
tance, for they must be responsible for advising or op- 
posing this method of treatment. 

Craniotomy, or the operation of producing an open- 
ing in the skull of some extent, with the object of 
relieving pressure on the brain, or in some unknown 
manner of stimulating its development, has been pro- 
posed and performed in a number of cases. 

Clinical Types of Different Kinds. 

These cases present certain clinical features, and 
may easily be divided into three general groups : First, 



TREPHINING FOR IMBECILITY. 115 

cases of hemiplegia with or without athetosis. Sec- 
ondly, cases of mental defects of various grades. 
Thirdly, cases of sensory defect of different types. 
Epileptiform seizures of petit mal or of grand mal 
type occur frequently in patients who may be assigned 
to any one of these groups, and may be the particular 
symptom in regard to which advice is sought. The 
subject, therefore, includes the question of trephining 
in organic epilepsy in childhood. 

I. Infantile cerebral hemiplegia has been studied so 
carefully of late, and so much has been, written upon 
it, that no elaborate description of the first class of 
cases is needed. The symptoms are the sudden devel- 
opment of a unilateral paralysis after a series of con- 
vulsions attended by high fever and its attendant dis- 
comforts, and a period of unconsciousness of varying 
duration ; then a gradual improvement in the paraly- 
sis after the active manifestations of the onset have 
subsided ; and, finally, a stationary condition, in which 
the face is but slightly affected in its voluntary or 
automatic movements ; the speech is usually regained, 
if it had been lost ; the arm is quite seriously para- 
lyzed, the fingers being stiff and a.wkward, and some- 
times being in constant slow involuntary motion 
(athetosis) ; the leg is held rather rigid, so that the 
child limps in walking and sometimes has a club- 
foot. There are, of course, on the one hand light 
cases in which the symptoms finally amount merely 
to clumsiness in the fingers. There are, on the other 
hand, severe cases in which a double hemiplegia has 



116 BRAIN SURGERY. 

occurred, both halves of the body being equally 
affected, and in which both arms are useless and both 
legs so stiff, so closely adducted, and so helpless that 
walking is impossible. These latter are cases in which, 
all the symptoms date from birth, the birth palsies of 
Gowers. In all cases the paralyzed limbs are found 
to be affected in their growth and development, so 
that they are smaller, colder, stiffer, and v/eaker than 
the others; the reflexes are exaggerated, but the elec- 
trical reactions are not qualitatively changed and the 
sensation is normal. This condition remains through 
life as a permanent defect, and although the division 
of contractured muscles or tendons and the applica- 
tion of ingenious apparatus may correct deformities 
and make the paralyzed parts fairly useful, and al- 
though the application of electricity to the muscles 
chiefly affected may increase their nutrition and thus 
prevent contractures which come from the unbalanced 
strain between the various muscles, yet any great 
degree of improvement is impossible. In more than 
one-half of these cases epileptic attacks are of frequent 
occurrence. 

These cases are so common that it seems needless to 
cite illustrative examples. In the well-known mono- 
graphs of Osier and of Sachs on the "Cerebral Palsies 
of Children," the most complete description of the 
varieties of the affection is to be found. In the his- 
tory of one of my cases, operated upon by Dr. 
McBurney — which is given later in this chapter — 
the ordinary course of the symptoms may be studied. 



TREPHINING FOR IMBECILITY. 117 

The chief clinical facts of importance in such cases 
are the time and character of the onset, the degree of 
spontaneous recovery, and the question whether the 
epilepsy is of so severe a type as to be dangerous. 

The cases which date from birth must be divided 
into those in which there has been evidence of trau- 
matism during labor, and uhose in which there was 
nothing about the delivery sufficiently unusual to 
awaken the suspicion of trauma. In the former class 
it may be stated confidently that cerebral hemorrhage, 
usually meningeal, is the cause of the symptoms. In 
the latter class it is probable that an intra-uterine en- 
cephalitis, or some unknown cause, has prevented the 
foetal brain from developing. I know of no positive 
means of differentiating these two sets of cases. The 
cases which have developed suddenly after birth are 
cases in which the ordinary causes of hemiplegia in 
adults have been acting, and, as Ashby has shown, 
must be traced either to encephalitis, hemorrhage, or 
embolism, or disease of the vessels. The degree of 
spontaneous recovery in any case can be pretty well 
determined by an examination at the end of the 
second year. It is evident that a complete cure never 
occurs. 

The fits in organic epilepsy are more likely to be 
frequent and severe than in idiopathic epilepsy. I 
have one patient who has had as many as twenty con- 
vulsions daily for weeks at a time. These fits do not 
destroy life, but of course render life a burden, and 
almost any means for their relief is justifiable. When, 



118 BRAIN SURGERY. 

however, they are infrequent they may be benefited to 
some degree by the use of bromides. 

II. The second class of cases presents mental de- 
fects rather than physical symptoms. The child may 
be slow in learning to talk, may seem unable to fix its 
attention upon anything continuously, may be exceed- 
ingly active, in constant motion — the activity being, 
however, aimless; may throw things about, or tear 
things up, or put everything into its mouth ; may be 
very difficult to manage because of its inability to re- 
tain and combine impressions with sufficient power to 
reason upon them ; and may, therefore, be incapable of 
appreciating the meaning of punishment, if this be 
inflicted. Such children may have good powers of 
perception, may recognize persons and objects, show 
pleasure at bright colors, or music, or caresses, but 
fail to show evidence of thought in the sense of rea~ 
soning power, judgment, or self-control. Some pa- 
tients constantly drool at the mouth, cannot be taught 
cleanly habits, and are manifestly imbecile. Other 
patients are quite bright in many directions, may even 
be precocious, show talents in music, or drawing, or 
fondness for mathematics, designing, languages; yet 
are apparently unable to appreciate moral ideas, can- 
not be taught to tell the truth, are cruel and bad, will 
not control any of their impulses, and so are the dis- 
tress and despair of parents and teachers. It is those 
mental qualities which are the product of the highest 
evolution which have failed to develop in this class of 
cases. The final result is that they have to be taken 



TREPHINING FOR IMBECILITY. 119 

care of all their lives, either at home or by attendants, 
being incapable of supporting themselves or directing 
their conduct. Many of them have epilepsy. One or 
two examples may be cited. 

G. M., now 21 years of age, has the appearance and 
manner of a boy of fourteen. His head is smaJl and 
narrow ; forehead retreating ; face small and expression 
stupid. He has always been a feeble-minded boy, never 
able to study long or to learn anything difficult, so that 
he is about oq the level of a boy of ten in his education ; 
and now, as he is becoming to some extent sensible of his 
defects, he is very moody, quiet, and retiring. He has 
always been hard to manage and prone to outbursts of 
temper, and in the past five years this irritability is in- 
creasing. He has also peculiar attacks. In an attack he 
is very restless, wanders about in an aimless way, hides 
or destroys anything he can lay his hands upon, and be- 
comes much excited, angry, and even abusive and violent 
if opposed. Such attacks last for three or four hours, 
during which it is necessary to watch him. After the 
attack is over he has no recollection of what has occurred 
or of what he has done. He has many symptoms of neu- 
rasthenia, probably due in part to self-abuse. He has no 
paralysis or defect of sensory power. He is able to read, 
write, play on the violin, and sketch, but cannot be em- 
ployed upon anything for any length of time, and there- 
fore is a burden to his family. 

I have three cases now under observation of children 
aged between three and five, who are apparently 
bright and capable of hearing and seeing properly, 
but who show no evidence of any desire or ability to 
learn to talk. They make crowing sounds of no special 
meaning, but any distinct articulation is never made, 
and attempts to teach them seem unavailing. All 



120 BRAIN SURGERY. 

three are restless, active children, easily attracted by 
interesting things, but incapable of fixing the atten- 
tion long on anything. They are usually in constant 
motion, running about, working with the hands, and 
cannot be quieted long. They appear to understand 
perfectly what is said to them, will do various things 
at command, notice music and noises, yet are as mute 
as though perfectly deaf. They present a fair degree 
of intelligence, though two of them are still unable to 
be taught to make any sign of desire to urinate, and 
hence are dirty. Yet to watch these children at play 
at home, one would not suspect any mental weakness, 
and were it not for the speechlessness the parents 
would not have suspected any defect. None have 
epilepsy as yet. 

III. The third class of cases is less common than 
the two preceding, and is likely to escape observation 
unless carefully investigated. The patients belonging 
to this class present no motor or mental defects, 
though they may be the subjects of epilepsy. They 
do have defects of sensory perception. It is probable 
that many cases of deaf -mutism belong to this class. 
Eheinhardt has described a case in which permanent 
deafness was due to manifest defects in the temporal 
convolutions of both sides. Dr. Donaldson has noticed 
a marked deficiency of development in the temporal 
and occipital convolutions of Laura Bridgman, who 
was both deaf and blind. The following case presents 
so many interesting features that I give the history 
in full: 



TREPHINING FOR IMBECILITY. 121 

The girl, who is now fourteen years of age, has suffered 
all her life from frequent attacks of petit mal and occasional 
attacks of grand mal, usually preceded by an epigastric 
aura, never by a visual aura, and her convulsions are gen- 
eral, never unilateral, in character. She has had from 
two to six attacks of petit mal daily, and grand mal at- 
tacks once a week, though at present, after three years of 
treatment by bromides, she has but three or four attacks of 
petit mal every week, and has had no grand mal attacks 
for two years. Her case, therefore, presents the features 
of an ordinary epilepsy. 

But upon investigation it was found that she had a 
slight divergent squint and a left bilateral homonymous 
hemianopsia, the visual fields in the eyes being much di- 
minished, not exactly symmetrically, and the field of vis- 
ion extending ten degrees beyond the fixation point in both 
eyes, while its periphery was slightly contracted even in 
the clear field. This condition had never been discovered 
until the child was eleven years of age, although from her 
infancy her mother had noticed that she habitually held 
her head toward the left side and looked at objects with 
her head turned somewhat to the left, as she does now. 
An examination by Dr. Webster for the purpose of cor- 
recting the squint led to the discovery of the partial 
blindness. The child is quite sure that she has always 
seen as she does now, that she has never been able to see 
objects approaching her from the left side. This she sup- 
posed to be natural. This fact is of some interest, as it 
confirms what has been stated before, that hemianopsia 
may remain undetected for years, or if noticed by a patient 
is supposed to be a blindness in the eye whose visual field 
is chiefly contracted. 

When a cause for this symptom was sought, it was 
ascertained from the mother that the child had been deliv- 
ered with much difficulty, that the labor was prolonged, 
that the head was greatly misshapen at birth, and had a 
large caput succedaneum over the posterior part. When 



122 BRAIN SURGERY. 

the child's head was inspected, it was found that over the 
right occipital region there was a very perceptible flatten- 
ing of the skull, so that the vertical parting of her hair 
was uniformly deflected to the right. The difference be- 
tween the two sides was easily noticeable on looking down 
upon the head from above, or by the aid of touch. It 
seems reasonable to suppose that this little girl has a de- 
fective development of the right occipital lobe of the brain, 
and that this involves the cortex and also the subcortical 
tract, since Wilbrand has shown with much reason that 
a purely cortical lesion produces symmetrical defects in 
the visual field, while subcortical lesions produce asym- 
metrical defects. The pupils respond to light thrown upon 
the blind field of the retina, hence the lesion is not in the 
optic tract. There has never been any hemiansesthesia 
or hemiplegia, hence the lesion is not in the thalamus or 
near the internal capsule. 

Peterson and Fisher have shown that cerebral atrophy 
in infants in the motor area is followed by an asymmetri- 
cal development of the skull, the depression in the skull 
lying over the atrophic part of the brain. Here there is 
present such a depression, or rather lack of convexitj^, 
over the occipital lobe to whose deficient development the 
symptom of blindness points. 

When, therefore, this patient presented herself for treat- 
ment for epilepsy, it became evident that she belonged to 
the class of cases in which the epilepsy was due to the 
organic disease or defect in the brain. 

It is interesting to note that a certain improvement in 
her condition — a marked diminution in the number of fits 
— has occurred under the influence of bromide ; but this 
has also been noticed in cases of epilepsy with hemiplegia 
of infantile origin. 

The important question to decide in this case is in 
regard to the possibility of any surgical interference. 
The history certainly points to the occurrence of great 



I 



i 



TREPHINING FOR IMBECILITY. 123 

congestion of the head during dehver}^, and the brain 
injury may reasonably be ascribed to a hemorrhage 
upon or in the occipital lobe. Such a hemorrhage 
compressing the lobe would prevent its growth, would 
finally be absorbed, leaving probably only a connective- 
tissue plaque or membrane. Now, it is known that 
brain-growth proceeds until the age of fourteen or 
thereabouts, and the question arises whether removal 
of this plaque would allow this brain to develop. It 
is hardly supposed that vision would be improved, but 
might not the epilepsy be benefited? As in the cases 
of hemiplegia and of mental defect, the question be- 
comes a pressing one, involving the future of the in- 
dividual. 

This case is not a unique one. Moeli has recently 
published {Arch, fur Psych., XXII., 2) three cases of 
hemianopsia due to defective development of the occi- 
pital lobe with porencephalus or great hydrocephalus, 
found in adults, one at least of whom had epilepsy. 
In all the affection must have dated from infancy. 
In none of these would an operation have been feasi- 
ble ; in fact, in all secondary degeneration had devel- 
oped even into the optic tracts. Henschen records 
two cases of infantile hemiplegia in which hemianop- 
sia was found ("Pathol, des Gehirns," cases 32, 38); 
and Freund {Wien. mecl. Woch., 1888, No. 32) also 
records two such cases. It is probable that the symp- 
tom has escaped detection in some cases of infantile 
hemiplegia from lack of examination. 

It is evident, then, that three separable types of 



124 BRAIN SURGERY. 

clinical cases of cerebral disease exist, any one of which 
may be accompanied by epilepsy. It is of course pos- 
sible that one case may present the symptoms of all 
the various types, and in fact there are many patients 
who present both mental defects, hemiplegia and sen- 
sory defects, as in a patient to be described later, on 
whom an operation was performed. One of these 
varying sets of symptoms, however, is usually more 
prominent than others, and hence it is hardly neces- 
sary to establish a fourth type including all such 
anomalous cases. 

When a patient belonging to one of these clinical 
types is presented to the neurologist and the question 
is asked, Can surgical treatment benefit him? it is 
evident that a serious problem is opened. In these 
cases the disease is at a standstill and does not threaten 
life ; surgical treatment is not free from danger, and 
the brain is still capable of great development. Can 
such development be aided by an operation? In many 
cases the epileptic attacks are of such frequent occur- 
rence that any risk might well be taken if they could 
be surely stopped. 

Any solution of the problem of operative treatment 
must be based upon two considerations: first, the 
pathology of the cases ; secondly, the results of experi- 
ence when such operations have been done. 

Pathological Conditions Present. 

Eecords of the pathological condition found in all the 
three classes of cases described are now accessible, col- 



j 



TREPHINING FOR IMBECILITY. 



125 



lections of cases with autopsies having been made by 
numerous writers. 

The lesions found are various in type, in origin, and 
in situation, but a careful study elicits two facts: 
First, that the difference in the clinical types is due to 
the varying situation of the lesion rather than to its 




Fig. 38.— a Frontal Section throuffh a Porencephalic Brain. The left hemi- 
sphere is normal. The right hemisphere is atrophied in toto, and has a cavity in 
the motor region which extends downward into the ventricle. The basal ganglia 
are atrophied. This condition is always congenital.— Shattenberg. 



varying nature. Secondly, that the various processes 
of disease have, as a fairly uniform result, a condition 
of atrophy with sclerosis of the brain, which we may 
term sclerotic atrophy. 

1. In the clinical cases of our first type the sclerotic 
atrophy involves the motor area of the brain, i.e., the 



126 



BRAIN SURGERY 



central convolutions bordering the fissure of Eolando 
and the cortex of their immediate vicinity, and in- 
volves also the motor tract arising from this part of 
the cortex, and usually the basal ganglia as well. In 
the clinical cases of our second type the sclerotic atro- 




FiG. 39.— Superior Surface of a Brain of a Congrenital Imbecile who had Hemi- 
plegia and Epilepsy. The entire right hemisphere is atrophied. C is the arach- 
noid, which was thickened and formed the wall of a cystic cavity in the hemi- 
sphere. — Ferraro. 



phy involves the anterior portion of the brain, and 
sometimes the entire hemisphere to a greater or less 
extent. In the clinical cases of our third type the 
sclerotic atroph}^ involves the posterior and lateral 
parts of the hemispheres. It is not surprising that 



TREPHINING FOR IMBECILITY. 



127 



the variation in the situation should produce varying 
symptoms, in view of the facts of the locahzation of 
brain-functions now known. That there should be 
a limitation of the sclerotic atrophy to certain lobes 
or regions — to the frontal, or central, or occipital, or 




Fig. 40. —Superior Surface of the Brain of a Congenital Imbecile. The arach- 
noid being removed the porencephalic cavity is displayed. The cortex is wholly 
defective over the upper frontal and parietal lobes and the cavity in the hemi- 
sphere opens into the lateral ventricle at D, in which the choroid plexus, e, is 
seen. — Ferraro. 

parieto- temporal regions — in various cases has led to 
the hypothesis that the origin of the disease lay in 
some interference with the blood -supply of the part, 
since it has often been evident that the atrophy was 
limited to the region nourished by blood reaching it 



128 BRAIN SURGERY. 

through one arterial trunk. And this hypothesis has 
heen supposed to explain the pathogenesis of these 
cases. Yet its weak point is the fact that at the 
autopsies the vessels usually show no evidences of dis- 
ease or of plugging, and the infrequency of vascular 
lesions in infancy cannot be denied. Schultze is doubt- 
less right in this matter in saying that the pathogene- 
sis of these defects is as yet quite obscure. 

2. It has been stated that the various processes of 
disease have, as a uniform result, a condition of scle- 
rotic atrophy. 

This fact is borne out by the following resume of 
results in 343 cases : ' 

Porencejjhalus, a localized atrophy or agenesis, leav- 
ing a cavity in the cerebral hemisphere, which may 
be deep enough to open into the ventricle, 132 cases. 

Fig. 38 shows this condition. The right hemisphere 
is smaller than the left, and has a funnel-shaped cav- 
ity leading directly downward from the side of the cor- 
tex into the lateral ventricle. ' 

Figs 39 and 40 also show a condition of porenceph- 
alus, the drawings being made before and after the 
removal of the pia mater. The right hemisphere is 
seen to be atrophied in toto, and the arachnoid is so 
thickened as to form an opaque wall of a cyst. On 

^ This number of cases has been gathered from the records of 
Kundrat, Audry, Wallenburg, Osier, Wilmarth, Feer, Henoch. Hirt, 
Fowler, Schultze, Sachs, Richardiere, Bourneville, Fisher, and from 
the American and foreign journals of the past three years, duplicates 
being sought and excluded. 

-This case is described by ShattcDberg in Ziegler's "Beitrage 
zur Path. Anat.," toI. v., p. 123, 1889. 



TREPHINING FOR IMBECILITY. 129 

removal of the pia the hrain cortex was found to be 
defective in large part and the cavity opened into the 
lateral ventricle. ' 

Sclerotic citropliy, an atrophic condition of the brain 
with an increase of connective tissue and disappear- 
ance of the nervous elements; affecting both hemi- 
spheres, or one only, or a part of one only; or limited 
to small areas in various parts, 97 cases. 

This condition is well shown in Figs. 41 and 42. 
They are photographs of a brain kindly put at my 
disposal by Dr. E. D. Fisher. The patient was a girl 
aged 19 at her death, who had been an imbecile and 
hemiplegic since birth and was subject to epilepsy. 
The condition was described by Dr. Fisher before the 
American Neurological Association in 1888, and this 
brain came from Case XXV. in his collection. 

Maldevelopment and apparent atrophic condition of 
the minute structures of the hemisphere, chiefly corti- 
cal, the cells resembling those of a new-born child, but 
with no apparent gross defects in the brain, 32 cases. 

Atrophy, consequent upon the condition of softening 
produced by embolism or thrombosis, and limited in 
extent to certain arterial districts of the brain, 23 
cases. 

Meningo-encephalitis, a condition shown by thick- 
ening and adhesion between the pia and the brain, 
with destruction of the cerebral cells and atrophy of 
the cortex, 21 cases. 

' This case is described by Ferraro in Revista Inter, d. Med. e 
Chir., Aug., 1886. 
9 



130 



BRAIN SURGERY. 



Cysts lying on the brain and producing atrophy by 
pressure, or associated with atrophy due to the origi- 
nal lesion of which the cyst remains as a trace, 14 



cases. 




Fig. 41.— The Superior Surface of the Brain from a Case of Sclerotic Atrophy 
of the Left Hemisphere. The entire hemisphere is atrophic, but the frontal con- 
volutions are less affected than the others. 



TREPHINING FOR IMBECILITY. 



131 



Hemorrhage on, or in, the brain, as shown by the 
remains of a clot, or by hsematin staining of a cyst, 
of the pia, or of the sclerotic tissue, 18 cases. 




Fig. 42. —The [nferior Surface of the Brain from a Case of Sclerotic Atrophy 
of the Left Hemisphere. The frontal lobe is not greatly affected. The left 
temporal lobe is very much smaller than the right one. The right hemisphere of 
the cerebellum is atrophic. The left pyramid of the medulla is smaller than the 
right one. 



mm 



132 



BRAIN SURGERY. 



Hydrocephalus with extreme dilatation of the ven- 
tricles, so that the brain tissue is reduced to a mere 
wall about the cavity. 5 cases. 

Unilateral hydrocephalus, 1 case. 

These are the conditions found at death in cases 
presenting the clinical features just studied. It is 
evident that they have this in common, namely, a 
condition of atrophy of the brain. The origin of this 




Fig. 43. — Distentoin of the Ventricles in a Case of Hydrocephalus ; a frontal 
section being made through both hemispheres at the posterior part of the optic 
thalamus, aa. Lateral ventricles ; b, descending horns of the lateral ventricles ; 
c, third ventricle; d, middle commissure.— Delafield and Prudden. 



atrophy is not always clear. In some cases it is clearly 
congenital and due to a maldevelopment of the em- 
bryo. In other cases it is clearly traceable to injuries 
at birth. Again, in other cases it must be ascribed to 
affections of various kinds, such as inflammations of 
the membranes, or of the brain substance, or vascular 
lesions and their consequences, such as occur in adults. 
It is not always possible, in a given case, to deter- 



TREPHINING FOR IMBECILITY. 133 

mine clinically the origin of the disease. For the 
absence of a history of trauma at delivery does not 
exclude necessarily a congenital lesion. And the ex- 
istence of certain symptoms in acquired cases does 
not always enable one to determine between an in- 
flammatory process and a vascular lesion. Thus fever 
of long duration and great severity is as likely to 
occur in hemorrhage or embolism as in meningo- 
encephalitis in infants. 

Nor are authorities by any means agreed as to the 
nature of the original pathological process of which 
the atrophy is the result. Wallenburg found, evi- 
dences of embolism in T cases and of hemorrhage in 
5 cases. Osier ascribes these causes to 16 cases in 
his collection. Ashby describes thrombosis in 3 cases, 
one of them due to syphilitic endarteritis, a very rare 
disease in infancy. McNutt found meningeal hemor- 
rhage in 12 cases. Gowers ascribes some of the birth 
palsies to thromboses of the venous sinuses. Kundrat 
has recently affirmed that a laceration of the veins 
entering the sinus is a sufficient cause for hemor- 
rhages during delivery. 

Henoch, Oliver, Sachs, Hirt, and others, have de- 
scribed a condition of meningo-encephalitis as present 
in these cases, and Wallenburg considered this the 
primary condition in 14 cases of his collection. Strum- 
pell's theory of an inflammation limited to the gray 
cortex has been discarded from lack of evidence. 
Thus it is evident that diseased states of the blood- 
vessels, their rupture or their plugging, or inflamma- 



134 BRAIN SURGERY. 

tory conditions of the meninges or brain, may be the 
primary conditions in many cases of sclerotic atrophy 
and of porencephalus ; conditions which vary very 
widely and which it is often impossible, clinically, to 
distinguish from each other. It is also evident that 
in quite a proportion of cases the origin of the atrophy 
must be a maldevelopment, whose real reason is wholly 
obscure. 

From this review it is apparent that many of the 
conditions are of such a nature as to be wholly un- 
affected by an operative interference. A porencephalic 
cavity, filled with cerebro-spinal fluid, is not likely to 
be benefited by any enlargement of the intra-cranial 
space, or by the abstraction of the fluid. In several 
cases operated upon the withdrawal of this fluid has 
been followed by sudden collapse and death.' On the 
other hand, there are conditions, such as maldevelop- 
ment of the cortex without gross lesion, in which it is 
possible that anything which may stimulate latent 
powers of growth, or may remove those influences 
which interfere with development, might result in im- 
provement. It is to be remembered that the brain is 
capable of growth and development until the age of 
twenty, if not longer, and granting that a stimulus 
to its growth may be given during childhood, that the 
arrest of development in many cases might perhaps 
have been prevented. 

^ Cases of Bullard : Boston Medical and Surgical Journal, Febru- 
ary 16th, 1888. Hammond : New York Medical Journal, August 
12th, 1890. 



TREPHINING FOR IMBECILITY. 135 

The study of the pathological condition, therefore, 
does not absolutely contra-indicate the operative inter- 
ference, although it makes it clear that the lesion in 
the majority of the cases is one which cannot be im- 
proved by any means. If we admit that porenceph- 
alus, atrophy from vascular lesion, meningo-enceph- 
alitisy and hydrocephalus are incurable, and that 
hemorrhages cannot be diagnosticated early enough 
to warrant the removal of the clot before it has caused 
atrophy from pressure, we have 193 cases out of 343 
in which operation would have been futile. This 
leaves 150 cases of sclerotic atrophy, maldevelopment 
of the cortex, and cysts, in which it is barely possible 
that an operation, if it relieved pressure or stimu- 
lated brain-growth, might have had some effect. It 
is only by the latter hypothesis that the apparent im- 
provement in certain cases can be explained. 

The unfortunate fact remains that it is impossible 
to ascertain the actual pathological condition present 
without an exploratory operation, as no clinical facts 
are at our disposal to enable a pathological diagnosis 
to be made. 

A suggestion is here offered incidentally, that when 
operation is undertaken the surgeon, before opening 
the dura, should, by manipulation or by exploration 
with a hypodermic needle, ascertain if possible whether 
a cavity in the brain exists beneath the opening in 
the skull, and if so avoid opening the dura lest the 
evacuation of this cavity result in death. 



136 BRAIN SURGERY. 



The Results of Experience. 

Let us review secondly the results of the experience 
of surgeons in the treatment of these cases by oper- 
ation. 

The operation of craniotomy has been done by 
many surgeons during the past three years, and the 
results have been reported by several of them, notably 
by Lannelongue, Keen, Bullard, Oppenheim, Frank, 
Hammond, Horsley, Agnew, and Park. Many other 
operators have reported single cases. ' 

The accompanying table of thirty-four cases gives 
the name of the operators, the journal in which the 
report is given, the age of the patient, the symptoms 
for which operation was done, and the result, with the 
time which had elapsed before the result was reported. 
Lannelongue 's cases are not included in the list. He 
stated at the French Congress of Surgery in Paris, in 
April, 1891, that he had operated twenty-five times 
with but one fatal result, and remarked in general 
terms that the patients — who were chiefly microceph- 
alic infants or epileptic children — improved after the 
operation. Lannelongue 's method of operation was 
to make a V or U shaped groove through the skull on 
one side, thus hoping to relieve intracranial pressure. 
As more precise facts are needed, these cases are ex- 
cluded from the table. 

' For a discussion of the metliods and dangers, Dr. Keen's able 
paper in the American Journal of the Medical Sciences, June, 1891, 
may be consulted. 



TREPHINING FOR IMBECILITY. 



137 



Table I.— Cases of Craniotomy in Children. 



Reporter. 



Bradford and Billiard : Bos 
ton Surgical and Medical 
Journal, February, 1888. 

Frank : American Journal 
of the Medical Sciences, 
July, 1890. 

Bartlett : Hahnemann 
Monthly, May, 1890. 

Oppenheim: Deutsche 
Medicinische Woe hen 
schrift. May, 1890. 

Hammond: New York 
Medical Journal, August, 



Trimble : Medical News, 
January, 1891. 



Wyeth : New York Medical 
Record, February, 1891. 

Anger : Progres Medical, 
April, 1891. 

Maunoury : Progres Medi 
cal, April, 1891. 

Maunoury : Progres Medi 
cal, April, 1891. 



Heurtaux : Progres Medi 
cal, April, 1891. 



Keen : American Journal 
of the Medical Sciences, 
June, 1891. 



Keen : Loc. cit. 



Keen : Loc. cit. 



Gerster and Sachs, report 
ed by Keen : Loc. cit. 

McClintock, reported by 
Keen : Loc. cit. 



Condition for which 
Operation was Per- 
formed. 



Age 
(Years). 



Hemiplegia ; imbe- 
cility. 



Double hemiplegia; 
imbecility. 



Hemiplegia; imbe- 
cility; epilepsy. 

Hemiplegia; epi 
lepsy. 



Hemiplegia ; imbe- 
cility ; epilepsy. 



Idiot ; had never 
walked ; micro- 
cephalus. 

Imbecility ; micro- 
cephalus. 

Imbecility ; micro- 
cephalus; epilepsy 

Microcephalus; epi- 
lepsy; idiocy. 

Double hemiplegia ; 
athetosis ; epilep- 
sy; idiocy. 



Microcephalus; epi- 
lepsy. 



Imbecility ; micro- 
cephalus; epilepsy 



Imbecility ; micro 
cephalus. 



Imbecility ; micro 
cephalus. 

Imbecility ; micro 
cephalus; epilepsy 

Idiocy; hemiplegia 
blindness. 



4}^ 



2 
4 

5J^mo. 

4M 

4^ 
3J^ 



Result. 



Death from shock 
in twenty hours, 
Porencephalus. 

Death from shock 
in three days. 



Recovery from op- 
eration. 

Paralysis improv- 
ed, fits less fre 
quent. 

Death from shock 
in five days. Por 
encephalus found 

Some improve- 
ment. 



Very great im 
provement. 

Improvement. 



Death in twenty 
hours from shock 

Improved for three 
months, then all 
symptoms re 
turned. 

Death from ex 
haustion in five 
weeks. 






10 days. 



2mos. 



1 mo. 



2 yrs. 



No marked im- 5mos. 
provement. Sec- 
ond operation 
three months 
later; no change. 



No improvement. 
Second operation 
three months 
later; no change. 

Death from shock 
in one hour. 

Death from shock 
in three hours. 

Improved. "Pa- 
ralysis almost 
disappeared." 



5mos. 



1 mo. 



138 



BRAIN SURGERY. 



Table I. — Cases op Craniotomy in Children. — Continued. 



Reporter. 



Condition for which 
Operation was Per- 
formed. 



Horsley : British 3Iedical 
Journal. September, 1891. 

Horsley : Loc. cit. 



WiUard, reported by Ag- 
new : University Medical' 
Magazine, October, 1891.1 

Morrison, reported by Ag- 
new: Loc. cit. 

Hammond : Medical News, 
October, 1891. 

Hammond: Loc. cit. 



Fisher : 3Iedical News, No- 
vember, 1891. 



McBurney and Starr: Medi- 
cal Record,,! anuary, 1892. 

Hartley and Starr: Medical 
Record, January, 1892. 



Preugmeber : Neurol. Cen- 
tral. January, 1892, p. 294. 

Park: Medical News, De- 
cember, 1892. 

Park : Medical News, De- 
cember, 1892. 

Park : Medical News, De- 
cember, 1892. 

Park : Medical News, De- 
cember, 1892. 

Park : Medical News. De- 
cember. 1892. 



Park : Medical News, De- 
cember, 1892. 

Park : Medical News, De- 
cember, 1892. 

Bennie : Kansas City Medi- 
cal Index, xiii. , 125. 



Idiocy; microceph- 
alus. 

Imbecility : micro 
c e p h a 1 u s ; epi- 
lepsy. 

Imbecility; athe- 
tosis. 



Imbecility. 



Aphasia ; trauma- 
tism; epilepsy. 

Hemiplegia : trau- 
matism; epilepsy 
at eight years of 
age. 

Insanity; epilepsy; 
trauma at two 
years of age. 

Hemiplegia ; e p i - 
lepsy. 

Imbecility ; epilep- 
sy; hemiplegia; 
aphasia. 



ImbeciUty. 
Imbecility. 



ImbecUity ; micro 
cephalus. 

Imbecility ; micro 
cephalus. 

Epilepsy ; imbe 
cility. 

Epilepsy; imbe 
cility; microceph 
alus. 

Epilepsy; imbe 
cility. 

ImbecUity. 



3Iicrocephalus ; im- 
becihty. 



Age 
(Years), 



Result. 



38 



30 



33^ 
4 

18 



12 
14 mo. 
10 mo. 



Some improve- 
ment. 

Death from fever 
on second day ; 
brain normal. 

Death on third 
day from scarlet 
fever. 



23^ Improved. 



Cure of aphasia 
and of epilepsy. 

Death in fifty days 
from exhaustion. 



Fits at first fewer; 
later, no im- 
provement. 

Improvement very 
marked. 

Improvement 1 n 
paralysis and 
aphasia ; fits, 
same. 

Improvement. 



Great improve- 
ment. 

No change. 

Death in twelve 
weeks. 

Death from shock. 



Great improve- 
ment. 



No fits for three 
months. 

No improvement. 
Death from shock. 



TREPHINING FOR IMBECILITY. 139 

It will be noticed that of Stt cases Itt died. This dem- 
onstrates that the operation of trephining is a more 
serious one in childhood than in adult life. Death has 
been due in 10 cases to shock from sudden evacuation 
of cerebro-spinal fluid, or from the severity and length 
of the operation, and under these circumstances it has 
occurred within a few hours or days of the operation. 
In 2 cases it has been due to exhaustion, and has not 
taken place within a month of the operation. This is 
a much greater mortality than occurred in Lanne- 
longue's experience. 

Two criticisms must be offered upon the reports of 
this class of operations. First, they are considered 
too exclusively from a surgical standpoint, and recov- 
ery from the operation may often be misconstrued as 
recovery from the original condition. Secondly, they 
are reported too soon after the operation to warrant 
any very positive statements regarding its perma- 
nent effects. ' In some cases the paralysis has been 
markedly relieved. In some cases the epileptic at- 
tacks have been said to be diminished in frequency 
and severity, or have been modified in character ; but 
when the undoubted fact is admitted that any opera- 
tion may modify the course of epilepsy," such state- 
ments must be subjected to the test of long observa- 
tion. It will be noticed that Maunoury reports an im- 
provement for three months followed, by return of 

^ See also criticism by Bourneville, Arch, de Neurol., 1893, No. 71. 
^ See Dr. J. William White on the supposed curative effects of 
operations per se: Annals of Surgery, August and September, 1891 



140 BRAIN SURGERY. 

the symptoms. In some cases a marked improvement 
in the mental condition has been reported, but here it 
is to be remembered that education and training will 
do much, and have been attempted perhaps more 
thoroughly after than before the operation. It is very 
desirable, therefore, that the medical reports in such 
cases should be more complete. 

As a contribution to this subject the three following 
cases are reported : 

Case XIV. Hemiplegia^ epilepsy, mental weakness — 
Trephining — Improvement. 
E. H., now 8 years of age, was born without difficulty, 
and Y/as a healthy baby until 5 months, when she was sud- 
denly seized with general convulsions attended by high 
fever and followed by left hemiplegia. For three weeks 
the temperature varied from 100° F. to 105° F., and con- 
vulsions recurred from time to time, the child being un- 
conscious almost all the time and being kept alive with 
difficulty. Then a gradual recovery began which had 
continued till the 6th year, when I saw her. She was still 
markedly hemiplegic on the left side, the face was noticeably 
affected when she made voluntary grimaces ; the arm was 
moved fairly well, but the hand was useless and the fingers 
were in constant slow motion of flexion and extension, this 
athetosis being much increased by any effort with the other 
hand ; the leg was moved well, though she dragged the 
foot a little in walking, and the ankle was quite rigid but 
not deformed, there being a tendency to talipes equinus. 
The paralyzed limbs were smaller than the others, but 
sensation was normal and electrical reactions were but 
slightlj' less than on the other side, there being no quali- 
tative change of reaction. Ever since the onset of the 
hemiplegia she had been subject to attacks of an epileptic 
character. She had numerous slight attacks daily, lasting 



TREPHINING FOR IMBECILITY. 141 

a few seconds, in which she seemed alarmed, ran to and 
grasped some one, saying she felt sick. Since the age of 
5 she has had severe attacks, chiefly at night, in which 
she cries out and has a short general convulsion, usually 
more marked on the left side, without biting the tongue 
or passage of urine. After such attacks she sometimes 
sleeps, sometimes goes on playing. In the past six months 
she had also had two very severe attacks of unilateral 
convulsions, there being a series in each attack. In these 
the spasm was first limited to the left face, the eyes turn- 
ing to the left; then to face and arm, then to face, arm, 
and leg, extending in this order, and finally the entire left 
half of the body was invaded in each spasm. Each spasm 
lasted about six minutes, the series lasting an hour and 
a half, and she was unconscious throughout. After these 
two attacks she was quite weak for a day or two, and the 
hemiplegia was more marked and the athetosis was per- 
ceptibly less. 

She had been petted much, and her parents think this 
is one cause of her being very fretful, irritable, hard to 
manage, and difficult to teach. The fact is that the child 
was deficient in the power of self-control and of voluntary 
attention, though her perceptions were keen and her mind 
active. All her sensory powers were perfect. 

The increase in the number and severity of the epileptic 
attacks, and the realization of the mental deficiency of this 
little girl, led the parents to desire an operation ; and with 
the distinct understanding that no positive result could be 
assured. Dr. McBurney trephined, at Roosevelt Hospital, 
on February 10th, 1891, at my request. A portion of 
skull about two by three inches was removed over the 
middle third of the motor portion of the right hemisphere. 
This point was selected by reason of the paralysis being 
more marked in the left arm and hand than elsewhere, 
because the athetosis was confined to these parts, and 
because the unilateral convulsion had affected these parts 
chiefly. The bone and dura were normal ; the pulsation 



142 



BRAIN SURGERY. 



of the dura, seen on exposure, was normal, and the 
sensation to touch made it evident that there was no 
cavity with fluid beneath the dura. The dura was there- 
fore divided, and the brain tissue exposed. The fissure of 
Rolando and the anterior and posterior central convolu- 
tions were recognized. The brain appeared to be perfectly 
normal. There was no evidence of the previous occur- 
rence of a hemorrhage, or of meningo-encephalitis, and no 




Fig. 44. —Diagram of the Situation of the Opening in the Skull in Case XIV. 

trace of atrophy. The dura was then sutured, the bone 
was not replaced, the wound Avas closed and healed 
promptly, and in two weeks the child was at home again. 
For one month after the operation the hemiplegia was 
more marked, and the athetosis much less ; then the pare- 
sis began to improve and the athetosis returned, and two 
years after the operation the hemiplegia ma}^ be said to 
be markedly improved, but the athetosis continues. The 



TREPHINING FOR IMBECILITY. 143 

severe epileptic fits with a cry which occurred n ightly, and 
the Jacksonian fits of which she had had two series in the 
six months prior to the operation, have not recurred. The 
petit mal attacks continued for two months after the oper- 
ation, and then began to diminish in frequency. The 
daily record shows the contrast between March and Sep- 
■ tember. In March she was having two or three attacks 
daily. In September she had fourteen attacks only, hav- 
ing had none at all during the first twelve days of the 
month. The parents believe that the mental condition of 
the child is markedly better, and that she is more capable 
of concentrating her attention. She has a more intelligent 
facial expression than formerly, but I am of the opinion 
that such mental improvement as has occurred is owing 
to more special and intelligent instruction and manage- 
ment than she had prior to the operation, and to the pro- 
gress of natural development. 

During the past two years she has had three peculiar 
attacks in which she has suddenly become alarmed, fret- 
ful, and appeared to be suffering. At these times the face 
has been flushed, and the scalp over the opening in the 
skull bulged perceptibly. She has not lost consciousness 
and has had no fit, but subsequently has appeared to be 
very weak, and for several minutes quite unable to move, 
and for an hour after has complained of tingling sensa- 
tions in the hand. Whether the opening in the skull has 
prevented a sudden cerebral congestion from irritating 
the brain and thus prevented a fit, may be regarded as an 
open question. That some marked change occurs in the 
intra-cranial pressure is proven by the marked bulging on 
each occasion. 

Case XV. Imbecility, epilejjsy, hemiplegia — Trephin- 
ing — Improvement. 
L. B., now 8^ years of age, was born prematurely, and 
was raised with difficulty. Her mother died of phthisis. 
At the age of 5 months she began to have convulsions, 
which had continued up till the time I first saw her, in 



144 BRAIN SURGERY. 

April, 1891. She was then having twenty fits in a 
day, each lasting from two to five minutes. At one 
time she had gone a month without a fit under bromide 
treatment. The girl had always been an imbecile, had 
failed to develop properly, and appeared like a child of 
four years. She was very microcephalic, all the meas- 
urements being much below the normal, but the skull 
was not asj'inmetrical. She had learned to walk and 
to talk, but suddenly, in November, 1890, after a fit 
was found to be aphasic and hemiplegic on the right 
side. The aphasia was complete when I saw her, hav- 
ing persisted for five months. She understood what was 
said to her, obeyed commands, but said nothing. The 
hemiplegia had improved, but her right hand was use- 
less and in a state of athetoid movement. It was less 
sensitive than the left hand. Her head-was in constant 
rotary motion. Examination showed a right bilateral 
hemianopsia. The aunt had noticed an increase in the 
mental dulness, and said that the child was too stupid 
to cry. 

While the appearance and the actions pointed to a con- 
dition of imbecility due to microcephalus, it was thought 
that the sudden onset of hemiplegia and aphasia, with 
hemianopsia, indicated either the occurrence of a hemor- 
rhage or beginning tubercular meningitis. With a view 
to the possibility of removing a clot, the child was sent to 
Roosevelt Hospital, where, at my request. Dr. Hartley 
operated upon her on May 15th, 1891. A piece of bone, 
about two inches in diameter, was removed from the skull 
over the lower part of the motor area and Broca's convo- 
lution, and this opening was then enlarged upward and 
backward. There was no bulging of the dura and no 
evidence of increased cranial pressure. When the dura 
was divided the cortex of the posterior part of the third 
and second frontal convolutions and the lower half of the 
anterior central convolution were exposed to view and 
recognized. No clot was found, no evidence of meningi- 



TREPHINING FOR IMBECILITY. 145 

tis, and the brain presented a normal appearance. The 
wound was therefore closed, the bone being left out, and 
it healed promptly without any complication. For six 
weeks after the operation no change was apparent in the 
condition, and the fits continued as before, from six to 
twenty daily. Then a marked improvement began. At 
present, sixteen months after the operation, the child talks 
freely, names objects at once, can answer simple questions, 




Fig. 45.— Diagram of the Opening in the Skull in Case XV. 

and sing children's songs. The hemiplegia has disap- 
peared entirely, but effort with the left hand produces 
associated motions in the right hand. All rotary move- 
ments of the head have ceased. Sensation seems keen in 
the right hand. There seems to be traces of right hemi- 
anopsia, but she is watchful of tests, though too stupid to 
give any accurate replies. She has been taught to keep 
herself clean, and is certainly more observant and obedient 
than formerly, though still imbecile. She is still having 
10 



J I ^^^^^^^^^^^^^a^^^mmm^^^^mtm 



146 BRAIN SURGERY. 

fits, about six daily. They do not yield to bromide or to 
chloral. I am wholly unable to explain the very marked 
improvement which has followed the operation, especially 
as there was nothing acccomplished by it at the time in 
the relief of local disease or of general pressure. 

In both cases it is interesting to observe that no gross 
defect of brain substance, no marked atrophy was discov- 
ered, and if lesions were present in the brain, they must 
have been of microscopic character. Is it possible that 
there was in both cases an arrest of development rather 
than an actual lesion, and that the effect of the operation 
was to stimulate the growth of cerebral tissue? 

Case XYI. Imbecility — Epilepsy — Microcephalus — 
Lineal^ craniotomy on both sides — Improvement. 
A little girl of eleven was brought to me on account of 
attacks of petit mal which had developed within two 
years and had become so frequent as to occur every 
hour. Two such attacks occurred in my office, each 
lasting twenty seconds, consisting of a sudden dilatation 
of the pupils, relaxation of facial expression, turning of 
the e3^es upward, falling backward of the head, and then 
recovery of balance just as she was about to fall. She 
was completely unconscious in the attack, had no warning 
of its onset, and no recollection of its occurrence. Slight 
stimulation of the surface anywhere — pinching, throwing 
water in the face seemed enough to arrest the attack, 
though loud sounds had no such effect. This child was 
well developed and very observant and active, but had no 
capacity for learning or for self-control. She had been 
trained with care, but could not read, and acted on every 
impulse. She was excitable, very quick in replies, im- 
pudent and saucy, delighting in doing everything which 
would annoy people, and it was im23ossible by punishment 
to effect any moral improvement. This defect of intelli- 
gence was associated by a very marked defect in the de- 
velopment of the forepart of her head. There appeared to 
have been a very early union of the coronal suture, so that 



TREPHINING FOR IMBECILITY. 



147 



a decided depression existed in the skull over its situation, 
and a marked difference could be seen between the size of 
the frontal bone and the posterior part of the skull. It 
looked as if a cap had been applied over the entire frontal 
bone which had arrested its growth, while the rest of the 
skull had developed properh^ The arch of the palate was 
high. In this case I advised an operation, which was un- 
dertaken by Dr. McBurney and performed during Decem- 




FiG. 46.— Diagram showing the Line of Incision through the Bone in Case XVI. 
The bony flap was elevated, being cracked across the dotted line. 



her, 1892. The object in view being to allow of growth of 
the frontal lobes, it was thought best to lift the bone away 
from the brain on both sides. The left side was first oper- 
ated on and two weeks later the right side. Both sides 
were done in the same manner. A long semilunar inci- 
sion was made in the scalp from the forehead near the 
temple backward to the mid -parietal region, its convexity 
being upward. A small trephine opening was made at 



■M 



148 BRAIN SURGERY. 

the summit of this incision, and with this as a centre a 
groove was chiselled in the bone, first downward and for- 
ward, then downward and backward. Thus an omega- 
shaped groove in the skull was cut. The bone was then 
gently pried up, the short limb of the omega between its 
ends being broken. Thus a bony flap with scalp attached 
was raised about an inch away from the dura. The dura 
was not opened. The wound was dressed so as not to 
make pressure on this flap. It healed by first intention, 
as did also the second wound on the other side. When 
the child went home the elevation of the two portions of 
bone was very perceptible. 

Her attacks ceased entirely between the first and the 
second operation, but returned with their usual frequency 
after the second operation. Mentally she seems brighter 
and is beginning to learn. 

Case XVII. Idiocy — Epilepsy — Hemiplegia — Trephin- 
ing — Death. 
A. H., aged 21, had been hemiplegic on the left 
side ever since birth, had never developed mentally, 
was a total idiot, unable to talk, dirty and drooling. 
Since the age of six months he had had frequent convul- 
sions which began in the left hand. The parents insisted 
upon an operation, and Dr. Weir consented to make an 
exploratory operation at the New York Hospital, February 
1st, 1892. The point selected for trephining was over the 
motor region of the arm on the right side. A large button 
of bone was removed and the opening enlarged with a 
rongeur. The dura did not pulsate and did not have as 
tense an appearance as usual. A hypodermic needle was 
thrust through it and did not encounter any resistance 
beneath, but could be freely moved about in a cavity. 
About a drachm of clear serous fluid entered the hypoder- 
mic syringe. It was evident that a porencephalic cavity 
lay beneath the dura, and as the opening of such a cavity 
was considered dangerous the wound was closed. During 
the following two days it was with much difficulty that 



TREPHINING FOR IMBECILITY. 149 

the patient was restrained. At last he succeeded in tear- 
ing off his bandages and died a few daj-^s later of menin- 
gitis. An autopsy was not allowed. 



Fig. 47.— Diagram of the Opening in the Skull in Case XVII. 

Dr. Eowell Park's experience with this new and rad- 
ical procedure has been sufficiently varied, interest- 
ing, and important to justify the individual recital of 
his cases. ' 

(1) J. v., aged 3 J years, was referred to me by Dr. 
Crego. As a baby he was restless and "jerky," and 
when 9 months old had convulsions of the entire body. 
As he grew older he would sometimes fall in some of the 
attacks. These slowly assumed the conventional epileptic, 
type, and by the time he was 3 years old, or in March, 

1 Medical News, Dec. 2d, 1893. 



IMRHI 



150 BRAIN SURGERY. 

1891, were perfect examples of grand mal. They also in- 
creased in frequency and severity. At that time he began 
staggering in his gait, and his left leg grew weak. Soon 
after it showed relative decrease in length and size. His 
temper became violent and uncontrollable, his epileptic 
seizures more and more frequent, and during the twenty- 
four hours previous to the operc tion he had between thirty 
and forty distinct and severe seizures. Though he was by 
"ho means an imbecile, his mental development was re- 
tarded. His skull seemed relatively small for his age. On 
June 21st, 1891, I operated on him at the General Hospital. 
A long incision, one inch to the right of and parallel with 
the middle line, was made from the forehead to the occiput. 
With cutting bone-forceps I excised a strip of bone 2 cm. 
wide from the line of growth of hair in front nearly to the 
occipital protuberance behind. Then detaching the scalp 
for the purpose, I excised a narrow strip of bone over the 
fissure of Rolando on the right side down nearly to the tem- 
poral fossa. The wounds were closed without drainage. 
During the ensuing twenty-four hours shock was severe, 
and the child had several violent epileptic seizures. Since 
this first day he has never had another. His irascibility 
has subsided, his general health and intelligence have im- 
proved ; he now runs, plays, acts, and talks just like other 
children of his age. 

(2) Minnie R., aged 4 years, was referred to me by 
Dr. Putnam. This was a case of congenital microceph- 
ajus and imbecility. The parents were healthy and the 
famil}^ history was good, the previous children being 
sound . This girl had scarcely ever spoken a word, and 
manifested no more intelligence than an infant of three 
months. Her fontanels closed very early. She leads a 
vegetable sort of existence — without disturbance of func- 
tion. Operation here seemed much less hopeful than in 
the previous case; it was, nevertheless, undertaken July 
13th, 1891. An incision was made 3 cm. to the left of the 
middle line, from 4 cm. above the left superciliary region 



TREPHINING FOR IMBECILITY. 151 

to the occipital protuberance. A strip of bone was excised 
much nearer to the middle line. After removing it the 
scalp was pressed away on the left side and a strip excised 
over the Rolandic fissure. I then made an incision over 
the right Rolandic fissure and excised another strip of 
greater length, the three lines of defect having a common 
meeting-place. The central grooves were cut with forceps, 
the lateral grooves with a chisel. There was no great 
hemorrhage, and the wounds were closed without any 
provision for drainage. The child nearly collapsed after 
the operation, and for two days required constant atten- 
tion. The after-results in this case have been practically 
nil. There has seemed to be a perceptible improvement 
in intelligence, and the child has appeared a little more 
alive to what is going on about her, and this is about all 
that can be said. 

(3) W. K., aged 18 years, was referred to me by 
Dr. Crego. From an. early age the patient's mental 
development has been very disappointing. He is physi- 
cally large and well developed, but mentally shows scarce- 
ly more intelligence than a child of two or three years. 
At the age of about five he first showed epileptic mani- 
festations. His seizures were then few and far between. 
They gradually increased in frequency, until now he has 
several in one day, but may possibly go a few days with- 
out any. His temper is usually good, but at times he 
is excessively wilful. The upper portion of his cranium 
is relatively small, though not conspicuously so. The 
muscles of his right side are somewhat atrophied. It 
seems that his epileptic fits have been somewhat more 
violent on the right side than on the left. His personal 
habits are good, as is also his family historj^ Dr. Crego 
and myself both thought that an extensive cranial opening- 
might give relief, and the experiment was proposed and 
accepted by the father. Operation was done October 20th, 
1891. A long incision was made to left of the middle line. 
When I endeavored to make a longitudinal division of the 



»■■■ 



152 BRAIN SURGERY. 

skull, commencing with a common amputating saw, I 
found that the bone was very thick. I then applied a 
trephine over the motor area, and, through the opening 
thus made, with chisel and gouge-forceps removed a por- 
tion of bone, some 5 cm. in diameter, and in shape like a 
spherical triangle. Through a small opening in the dura 
I found that there were no adhesions, but that the arach- 
noid and pia were succulent and cjedematous. I started to 
make a longitudinal excision of bone, but finding the same 
to be 1 cm. thick, desisted from this attempt and tried to 
make simply a large relief-opening. The wound was 
closed with catgut and an ice-bag applied outside the 
dressing. At 6 P.M. the boy was somewhat restless and 
had a fit. This condition became more marked, and by 
midnight, in spite of considerable morphine and other 
sedatives, he was convulsively restless and violent and 
required both a strait-jacket and chloroform. At 4 A.M. 
he died of exhaustion. 

(4) J. M., aged 15 years, was healthy until he 
was three years old. Then his nurse used to frighten 
him, and he grew to be very nervous and timid. He soon 
began having fits every night, until he was 13 years 
old, when they occurred in the daj^time also. Shortly 
after this he was having from thirty to forty fits every 
day. During one of these he fell and broke his elbow, 
which is now partially ankylosed. He also cut his fore- 
head to the bone. For the last two years he has been 
lying most of the time helpless in bed and has had to be 
fed. His symptoms, mental and convulsive, seemed to 
occur in cycles of about three weeks each. During the 
first week of the three he would be noisy, in the second he 
would be weeping and wailing, and during the third 
apathetic and almost unconscious. He rarely spoke. All 
the children of this family were rachitic, l^ovember 2d, 
1891, the boy was brought to my clinic in this third stage, 
and it seemed impossible to arouse him. He took mechan- 
ically most of what was put into his mouth. His bed 



TREPHINING FOR IMBECILITY. 153 

was constantly soiled. His arms, and sometimes his legs, 
were nearl}- always in the athetoid condition, and anj" little 
disturbance would bring on a mild seizure, during which 
his arms were drawn up over his head. There were no 
scars over his motor areas. November 7th, 1891, the opera- 
tion was carried out at my clinic. A long incision was made 
to the left of the middle line, and after a first opening of 
the trephine a long strip of bone, 1 cm. wide and 13 cm. 
long, was removed just to the left of the longitudinal 
sinus. The operation had to be discontinued because of 
collapse. The patient stopped breathing, nearly died on 
the table, and was revived with great difficulty. The 
wound was closed as rapidly as possible. He seemed 
better the same evening, but next day the athetosis contin- 
ued ; he became uneasy and died, twenty-six hours after 
the operation, of shock. 

(5) S. P., aged 9 years. This patient is of Rus- 
sian-Jewish parentage, his father being an educated man 
and the other children healthy. He presents a defec- 
tive skull-development, especially over the left frontal 
lobe; is imbecile and epileptic; has seizures coming on 
about every five days. His forehead slopes backward so 
as to give him somewhat the appearance of an Aztec child. 
Mentally he is an imbecile, mutters half a dozen words, 
staggers about the room, but in disposition is good-natured 
and even confiding. He was operated upon November 
11th, 1891, at my clinic. In this instance I varied the 
ordinary procedure in that I laid up a V-shaped frontal 
flap, its apex reaching nearly to the vertex of the skull, 
its extremities extending nearly to the external angular 
processes. Then a small trephine was applied on each 
side of the middle line ; the opening thus made was con- 
nected across the longitudinal sinus, and then two strips 
of bone were excised in a direction parallel to the scalp- 
incisions, by which considerable spring was given to the 
frontal bone and the fragments of others attached to it. 
The operation proceeded without incident, and the first 



154 BRAIX SURGERY. 

dressing vras not made until eight days later, when per- 
fect union was found. The immediate effects in this case 
were not very pronounced ; the seizures, however, became 
less frequent and less severe, and when the boy left the 
hospital a few weeks later he had lost his staggering gait, 
and his various actions and attempted speech showed 
much more fixedness of purpose than was previously the 
case. But at the end of a year the results in his case have 
to me been astoimding. He has had no fit for three 
months, and within a week or two was again exhibited at 
my clinic. He came up to me and publicly asked in clear 
and distinct tones whether he could go to school. I held 
some conversation with him before my class, in order to 
show that he was capable of rational thought and rational 
and even accurate conversation. In addition to this he 
has developed physically, and his face now has a really 
intelligent expression, whereas a year ago it was expres- 
sionless. 

(6) C. S., aged 12 years, of Warren, Pa., was sent 
to me by Dr. Baker. This child was also an imbe- 
cile, speaking but few words, being at times irascible 
and having at times frequent epileptic seizures. There 
was partial paresis of the left arm, although she used it 
more or less. In her case there was great asymmetry, 
there being a great depression over the right side. Shoj 
was operated on the same day as the previous case at a 
special clinic given for these two cases, and a strip of bonej 
about 1 cm. wide was excised to the right of the middle 
line, extending well backward and forward into the frontal i 
bone. The dura was not opened. At the first dressing, 
one week later, perfect imion of the wound was found, 
and a light dressing only was api^lied. A few hours later' 
she got restless and tore this off, and then picked the 
wound open so that it gaped for its whole distance. It 
was immediately re-dressed after disinfection with hydro- 
gen dioxide, but healed the second time by the slower) 
process of granulation. During the few weeks of her stay 



TREPHIXIXG FOR IMBECILITY. 155 

in the hospital she improved a little. A letter from Dr. 
Baker, dated October 25th, 1892, nearly a year later, states 
that " she is no better now than she was before operation. 
For the first three months after operation there was a 
marked lessening in the number of paroxysms, but for the 
last three months the convulsions have been both severe 
and frequent, she having several daily. She is in much 
the same condition mentally that she was before operation. " 

Conclusions. 

From this review of the clinical types of cerebral 
atrophy in childhood, of the pathological conditions 
producing these types, and of the results of surgical 
treatment by craniotomy, the following conclusions 
may be drawn : 

1. Hemiplegia, sensory defects, and imbecility oc- 
curring with or without epilepsy in children are 
chronic diseases, incurable by medical treatment. Any 
means which may be legitimately used to save the in- 
dividual from a life of invalidism, and to take the 
burden of his care from the family, is to be employed. 

2. The pathological conditions producing these 
symptoms may be either gross defects and atrophies 
of the brain, or an arrest of development in the cere- 
bral cells, without any change which is apparent to 
the naked eye. 

3. It is at present impossible to determine absolutely 
the pathological condition present in any given case, 
without an exploratory operation. 

4. Such operations are not without danger, but if 
caution is used in opening the dura, and if the opera- 



156 BRAIN SURGERY. 

tion is made as short as possible, the dangers are 
avoided. 

5. When manifest atrophies are present the opera- 
tion will not produce any result. When the condition 
is one of arrested development of cerebral tissue, it 
may prove of service. When clots, cysts, or tumors 
are found and removed, the chance of recovery is in- 
creased. When the skull is markedly microcephalic 
from early union of the sutures, the increased space 
given to the brain by the operation appears to stimu- 
late its growth and development. 

6. Epileptic attacks are frequently reduced in fre- 
quency and modified in character by craniotomy. 
When the opening of the skull remains covered only 
by the soft tissues, it appears to act as a safety-valve, 
allowing changes in the intra-cranial contents to occur 
without producing pressure upon the brain. 

7. Hemiplegia, aphasia, athetosis, and sensory de- 
fects have been relieved by operation, and in a num- 
ber of cases the mental condition has been greatly im- 
proved. 



i 



CHAPTEE IV. 

TREPHINING FOR CEREBRAL HEMORRHAGE. 

Records of Cases of Clots Removed from tlie Brain, Report of Per- 
sonal and Selected Cases. The Symptoms of Traumatic Cerebral 
Hemorrhage. The Differential Diagnosis Between Intra-Dural 
and Extra-Dural Hemorrhage. Operations for Non-Traumatic 
Hemorrhage. 

In the remarkable paper which Macewen read be- 
fore the British Association in 1888, he described three 
cases in which he had removed clots from the surface 
of the brain, having been guided in all these opera- 
tions by symptoms which indicated an affection of 
the motor area of the cortex. 

The first of these cases was one of paralysis in the 
left half of the face and left arm, in which the clot 
was found lying over the lower third of the motor 
area. The operation in this case was done in 1879. 
In 1883 two similar operations were successfully per- 
formed : the first for the relief of paralysis of the arm ; 
the second for the relief of paralysis of arm and leg. 
All three cases had developed symptoms subsequently 
to an injury, all three were suffering from general 
symptoms of compression, and all three recovered 
completely after the removal of the clot. 

Between that time and the present about thirty 
cases have been reported of successful attempts 



158 BRAIN SURGERY. 

to remove clots from the brain. The majority of 
these have been cases of hemorrhage developing with- 
in a few hours after the occurrence of an injury to 
the head. A few of them have been cases of spon- 
taneous intracranial hemorrhage without external 
injury. 

Traumatic Hemorrhage. 

In cases recorded by Ball and Schneider pene- 
trating wounds inflicted by a knife in the left temple 
gave rise to gradually increasing symptoms of cere- 
bral compression with the development of total aphasia 
and slight right-sided paralysis. In both these cases 
the exposure of the dura by trephining the skull re- 
vealed it to be pulseless and deeply stained by blood, 
and its division revealed the existence of a large clot, 
black and tarry, which was easily removed in both 
€ases. The patients recovered completely the use of 
speech, but in Schneider's case the slight facial paral- 
ysis remained even at the end of six months. 

Ball's case is as follows: ' 

F. B., set. 26, admitted September 1st, 1887, had been 
struck on the head with a penknife ten daj^s before com- 
ing under observation. Since the accident he had found 
difficulty in using the right words — for instance, he said 
he had a " man" in the side of his Taead, when be meant 
^'pain." He did not appear to be able to understand 
everything which was said to him and he was unable to 
read and to write at dictation. Upon examination a small 
scab was found adherent to the scalp, over the squamous 
portion of the left temporal bone; this, when detached, 
1 Dublin Journal, 1888, vol. 86, p. 343. 



TREPHINING FOR CEREBRAL HEMORRHAGE. 159 

showed a cicatrix, apparently extending deeply through 
the temporal muscle, but the wound was quite healed. 
He was unable to name correctly articles which were 
shown to him, while in speaking he constantly used wrong 
words or parts of words. There was no paralysis whatso- 
ever to be detected of any of the voluntary muscles when 
he came under my observation. Five days after his ad- 
mission his symptoms had so much increased that it was 
determined to operate. A flap was turned down, includ- 
ing a portion of the temporal muscle and containing in its 
centre the cicatrix ; this disclosed a wound of the squamous 
portion of the temporal bone of a size and shape likely to 
be produced by the small blade of an ordinary penknife. 
A medium-sized trephine was now applied, and a circle 
cut out, containing in its centre the cut in the bone ; this 
was attended with some difficulty, as the lower part of the 
circumference was exceedingly thin, while the upper por- 
tion was tolerably thick ; the piece was, however, removed 
without injury to the dura mater by the trephine. It was 
found that the knife had perforated the dura mater and 
brain. The wound in the dura mater was enlarged, in 
doing which the large posterior branch of the middle men- 
ingeal artery was divided, and gave some little difficulty 
to control. A sinus forceps was gently passed along the 
brain wound and the blades separated, when a dark- 
colored blood- clot presented and was graduall}" extruded by 
the internal brain pressure. Some more fragments of clot 
were removed by the sinus forceps and by a stream of 
weak perchloride of mercury solution from a syringe. A 
drainage tube having been introduced, the flap was re- 
placed and held in position by deep sutures. On the 
evening of the same day the patient was much more ra- 
tional. Next morning he was again more aphasic, and 
it was found that the drain had become blocked. Upon 
freeing it a considerable quantity of broken-down blood- 
clot was removed, and his power of speech improved. 
He made an uninterrupted recovery. 



160 BRAIN SURGERY. 

Sclineider {Arcliiv fl'ir klinische Chirurgie, Bd. 
XXXIV. , Heft 3) publishes the following history : 

The patient was a young man, 18 years old, who was 
stabbed with a knife in his left temple, and who had, 
almost immediately, paralysis of the right side of the face 
and of the right arm and leg. Four days afterward he was 
brought into the hospital in Konigsberg. He then had a 
small, almost healed wound over the third frontal con- 
volution. He was perfectly conscious and could answer 
by signs, although he could not speak a word. As the 
hemiplegia increased without febrile symptoms, Schneider 
attributed it to an accumulating extravasation of blood 
and operated for its relief on the ninth day after the in- 
jury. He trephined the skull at the seat of the wound, 
opened the dura, removed a small clot, found the first 
branch of the middle cerebral artery spurting in the sub- 
stance of the brain, seized it with forceps and li gated it 
with catgut. The wound was then cleansed, the opening 
in the dura was sutured with fine catgut, the soft parts 
covering the skull were also sutured, a drainage tube was 
inserted, and a Lister bandage was applied. The wound 
healed by first intention. On the third day after the oper- 
ation the patient began to articulate, and in four weeks he 
spoke perfectly. Part of the hemiplegia disappeared more 
rapidly, the leg and arm recovering in eight days ; but the 
facial paralysis was not wholly gone after a lapse of six 
months. 

In cases recorded by Owen,' Walker," Winkler,' 
Homans,' Allingham," and Croft," cerebral symptoms 
of the nature of paralysis developed within a few 



1 Owen : Brit. Med. Jour. , Oct. 13th, 

2 Walker : Med. and Surg. Reporter, 1890. 

3 Winkler: Brit. Med. Jour., Aug. 22d, 1891. 
^Homans: Bost. Med. and Surg. Jour., June, 1890. 

5 Allingham : Brit. Med. Jour. , Apr. 20th, 1889. 

6 Croft : Lancet, Jan. 10th, 1889. 



TREPHINING FOR CEREBRAL HEMORRHAGE. IGl 

hours of a severe injury attended in two of the cases 
by fracture of the skull. In these cases the surgical 
condition indicated trephining, and in all of them the 
necessity of relieving cerebral compression and of ar- 
resting the increasing paralysis led to the opening of the 
dura and to the extraction of clots which were found. 
In all of these cases the symptoms gradually subsided 
and the patients made a good recovery not only from 
the operation but also from the cerebral symptoms. 

In cases recorded by Duret, ' Brewer and Carson,* 
Mouisset," and Armstrong,* the cerebral symptoms had 
developed after injuries, but had come on slowly and 
had not been associated with any fracture of the skull. 
In these cases an operation was not performed until 
several weeks subsequently to the injury. In all of 
them the operation was guided by the symptoms of 
paralysis or of aphasia, and in all of them the clot 
was found, removed, and the patient recovered. 

A somewhat similar case is the following, which was 
published by Dr. McBurney and myself two years ago : ^ 

Case XVIII. Traumatic hemorrhage from a vein of 
the pia mater — Compression of Broca's convo- 
lution and of the sensori-motor area of the cortex 
— Aphasia — Partial iHght hemiplegia and hemian- 
cesthesia — Trephining — Removal of clot — Recovery. 
History. — A phj^sician, aged 40, was thrown from his 

carriage on August 17th, 1889. He was slightly stunned 

^ Duret: La Semaine Medicale, Apr., 1891. 

2 Brewer aDcl Carson : Amer. Jour. Med. Sci., Feb., 1892. 

3 Mouisset : Lyon Medical, 1889, p. 204. 

■* Armstrong: Jour. Amer. Med. Assoc, 1891. 
^ Brain, PartLV., p. 254 
11 



162 BRAIN SURGERY. 

b}^ the fall, but had no wound, and was able to help his wife, 
who appeared to be injured, to reach home. For several 
hours he seemed to be suffering merely from bruises, and 
was able during the afternoon to converse with a patient and 
to administer a hypodermic injection. In the course of 
the evening, however, he became delirious, then stupid, 
and for the following three days he lay in a semi-comatose 
condition. On the morning after the injury he was found 
to be completely hemiplegic on the right side and aphasic. 
When, after a week, his consciousness had fully returned, 
it appeared that the aphasia was purely motor, as he could 
understand what was said to him and could read. The 
hemiplegia was attended by a partial ansesthesia, the 
paralyzed limbs felt numb, were less sensitive to touch and 
to pain, but acutely sensitive to cold and to heat. In this 
condition he remained until December, when he was 
brought to IN'ew York and admitted to Roosevelt Hospital, 
where he was seen by us. 

Examination. — The patient, a large man, was unable 
to say anything, even ''3-es" or "no," the vowel sounds 
being the only sounds produced by effort. He evidently 
imderstood questions, and attempted to reply by gestures 
and by trjang to write with his left hand. It was noticed, 
however, that he was mentally dull, so that the result of 
tests of muscular sense were not satisfactory, though he 
could be tested for tactile and pain senses, which were 
found to be impaired on the paralyzed side. He was 
emotionally unstable, laughing too readily and at times 
appearing to be much depressed. Ophthalmoscopical ap- 
pearances were normal. Sight and hearing were normal. 
The right hemiplegia was partial. He could turn his eyes 
in all directions, but could not turn his head to the right. 
His left pupil was one-third larger than the right pupil, 
but both reacted normally. His face was slightly flat but 
not paralyzed, and his tongue protruded straight. His 
arm Avas almost totally paralyzed, the only motion possi- 
ble being a slight abduction at the shoulder. His leg 



TREPHINING FOR CEREBRAL HEMORRHAGE. 163 

could be moved a little at the hip and knee, and when held 
up by two persons he could drag the leg forward a little, 
but could not stand alone. The hand was flexed and 
pronated, the leg was extended; both were very rigid; 
and all the deep reflexes were greatly exaggerated, so that 
wrist and finger clonus, as well as patella and ankle clonus, 
were easily produced. He controlled his sphincters per- 
fectly. There were no scars upon the head. 

Diagnosis. — It seemed probable that as a result of the 
fall there had been a rupture of a small vessel, from which 
YQi'j slow hemorrhage had taken place; the vessel was 
thought to be a vein rather than an artery, because of the 
very slow development of the symptoms. The situation 
of the clot was thought to be upon the surface and not 
within the left hemisphere, and it was located upon the 
posterior part of the third frontal convolution and over the 
anterior central convolution in its middle third, as shown 
in the diagram. A flat clot in such a situation might fail 
too compress the face area, and could produce an abso- 
lutely total motor aphasia ; while a sub-cortical or cap- 
sular clot could hardly produce total permanent motor 
aphasia and paralysis of the arm without producing pa- 
ralysis of the face and tongue. On the strength of this 
diagnosis it was thought best to operate. 

Operatio7i. — On December 13th, 1889, Dr. McBurney 
trephined the skull. The trephine was applied at a 
point one inch and seven-eighths behind and seven- 
eighths of an inch above the external angular process of 
the frontal bone, and the opening was then enlarged by 
the rongeur forceps upward and backward, the dura being 
laid bare over an ovale area three by two inches. The 
dura did not pulsate. On opening the dura the pia was 
found to be very oedematous and discolored, and the sur- 
face of the brain was separated from the dura by a space 
of half an inch in depth and did not pulsate. The clot 
was seen lying beneath the pia upon the posterior part of 
the third frontal convolution, and extending over the an- 



164 



BRAIN SURGERY. 



terior central convolution in a thin layer (marked in lines 
on Fig. 49) into the fissure of Rolando, which was 
filled with a larger clot lying in the situation shown in the 
diagram, and extending downward so as to fill up and 
distend greatly the cul-de-sac at the lower end of the fis- 
sure. The clot had not covered the lower third of the an- 
terior central convolution and had not reached the upper 
quarter of the fissure of Rolando. The brain, at a dis- 




FiG. 48.— Diagram to show the Opening in the Skull in Case XVIII. 

tance of an inch about it, appeared to be healthy and pul- 
sated, but the parts of the cortex on which the clot lay 
were pulseless and stained a yellowish-red. After the pia 
had been incised the clot was removed little by little by 
fine sponges — at least a drachm of partly organized clot 
being taken out of the fissure of Rolando. The retraction 
of the brain from the skull was even more evident when 
the operation was complete. The operation was done 
under strict aseptic precautions, and was not followed by 



TREPHINING FOR CEREBRAL HEMORRHAGE. 165 

an}' rise of temperature. The wound was dressed in the 
open method, being packed with gauze and drainage 
tubes being inserted. On renewing the dressings three 
days subsequently to the operation it was found that the 
entire surface of the brain was pulsating normally, and 
that the brain surface presented a normal color and ap- 
pearance. After a week the drainage tubes were removed, 
and after three weeks the wound had entirely healed, the 
level of the scalp at the bottom of the cavity being an inch 
below the normal level. 

Result. — On the evening of the day of operation the 




Fig. 49. —Diagram of the Left Hemisphere of the Brain, showing the Situation of 
the Clot in Case XVIH. 

patient said yes and no for the first time since the injury, 
and since that time his recovery of speech and of power 
has been progressive. After a few days it was noticed 
that he was much more intelligent and no longer emo- 
tional. Power in his leg began to increase very soon, and 
two months after the operation he was able to walk with a 
cane. The return of speech was slow and continuous, and 
it appeared as if he were learning a new language. He 
repeated words after another until he had learned them. 
He talked in monosyllables for the first three months, 



166 BRAIN SURGERY. 

then he began to put two words together, and then nsed 
short sentences of three or four words. At the present 
time, three years after the operation, he is practising 
medicine in his native town, is able to walk without a 
cane, can name at once any object showm him, but in talk- 
ing uses only a few words at a time, not speaking fluently, 
writes with his left hand, and were it not for the loss of 
power in the right hand might be considered fairly well. 
The paralysis of the right hand remains, and with it a 
marked diminution of tactile and pain senses, two points 
being felt as one when 2 cm. apart on the tips of the fin- 
gers. The muscular and temperature senses are perfect. 
He can move the arm and forearm in all directions with 
much force and can supinate the hand, but movements 
below the wrist are very slight, the fingers being flexed 
and rigid. The reflexes are much less exaggerated than 
before the operation, clonus not being elicited excepting 
at the ankle ; the head can be turned in any direction, and 
the pupils are equal. 

Stanley Boyd reports the following case in the 
Clinical Society's Transactions for 1892, p. 157: 

M. J. L., male, 10, fell from a horse March 31st, 1891, 
was stunned, but walked upstairs and went to bed ; was 
dazed ; had swelling over left side of head, but no scalp 
wound. Had some pain in head for two weeks, when he 
was able to get up and go to work. On June 18th head- 
ache began again and right hand became clumsy. June 
22d he was dull, confused, silly, and memory was bad, had 
paralysis of right hand and right leg was weak. The 
right hemiplegia increased and he became comatose and 
had fever. 

He was trephined on June 28th, 1892, on the left side 
over the arm centre. On dividing the dura a cyst was 
seen, and when incised, four ounces dark red clear fluid 
escaped. This was drained. He was delirious for nine 
days, but gradually improved and was discharged from 



TREPHINING FOR CEREBRAL HEMORRHAGE. 167 

the hospital August 15th quite well. He had remained 
iu perfect health up to May, 1892, when the report was 
made. 

The cases cited are sufficient to demonstrate the 
possibility of trephining for cerebral hemorrhage. ' In 
traumatic cases where there is a history of punctured 
wound, or of a fracture of the skull, or of a severe 
fall upon the head, the development of symptoms of 
compression together w^ith local symptoms of uni- 
lateral paralysis leaves little doubt in regard to the 
diagnosis. Hemorrhage upon the surface of the brain 
subsequently to injuries is usually due to a rupture of 
one of the veins in the pia mater; the hemorrhage 
occurs slowly, the clot spreading itself out beneath the 
f)ia or upon it in a broad thin layer ; the blood settles 
in the depths of the fissures separating their sides, 
producing pressure upon the brain adjacent and be- 
neath it. Such pressure developing gradually is some- 
times sufficiently irritating to give rise to spasms or 
localized convulsions, and it is usually enough to arrest 
the functions of the cortex and produce paralysis if 
the clot lies in the motor region, or aphasia if it lies 
in the aphasic regions, or hemianopsia if it lies in the 
visual area. The gradual onset of these symptoms is 
a strong indication of the occurrence of a surface 
hemorrhage. The general symptoms of compression 
of the brain must be associated with these local symp- 

' Lamphear has trephined for cerebral hemorrhage. The histtn-y 
is, however, too imperfect and the report made too soon after the 
operation to warrant its reproduction here. See Amer. Jour, of 
Surg, and Gyn. , Jan. , 1892. 



168 BRAIN SURGERY. 

toms in order to establish the diagnosis. Such symp- 
toms are a condition of stupor which gradually deepens 
into coma with stertorous breathing, a slow and some- 
times irregular pulse, a rise of temperature to 101° to 
103°. Suppression of urine and polyuria have both 
been observed, and an appearance of albumen or sugar 
in the urine is not infrequent; vomiting occurs if the 
patients are not deeply comatose. Irregularity of the 
pupils with dilatation on the side of compression has 
been noticed. 

Extra-Dural vs. Intra-Dural Hemorrhage. 

In any case of injury of the head, either with or 
without a fracture of the cranial bones, followed at 
once by marked cerebral symptoms, the question will 
arise whether the hemorrhage which is probably caus- 
ing the symptoms is extra-dural or intra-dural. This 
question it is often very difficult and sometimes im- 
possible to decide. Extra-dural hemorrhage is almost 
uniformly from the middle meningeal arter}', but 
intra-dural hemorrhage may occur at any part of the 
brain surface. The question will only have to be de- 
cided, then, in those cases which present symptoms of 
paralysis — for hemorrhage from the middle meningeal 
causes pressure whose greatest intensity is over the 
central convolutions, and quite uniformly produces 
hemiplegia. The symptoms of middle meningeal hem- 
orrhage have been most completely analyzed and de- 
scribed by Jacobson in Guy's Hospital Eeports for 
1886, the conclusions being based on a study of TS 



TREPHINING FOR CEREBRAL HEMORRHAGE. IGO 

cases. Jacobson calls attention to the fact that the 
violence causing a rupture of the middle meningeal 
artery is often slight and insufficient to produce a 
fracture. He mentions the following symptoms of 
such a hemorrhage in the order of their value : 

There is usually an interval of lucidity or conscious- 
ness between the concussion and the appearance of 
pressure symptoms, such as somnolence, stupor, and 
coma. This interval may be only an hour, but it may 
be even ten days. A long .interval would be much 
less likely to occur in intra-dural hemorrhage. 

Hemiplegia occurs on the side opposite to the injury, 
face, arm, and leg being usually affected, but the leg 
to a much less degree than the arm, and never alone. 
This is easily understood when it is remembered that 
the leg centres lying near the vertex will not be 
greatly compressed by a clot in the region of the middle 
meningeal artery (Fig. 50) . There is no particular rea- 
son why an intra-dural clot should not involve the leg 
as well as the arm or should not affect it alone. Con- 
vulsions rarely precede the onset of the hemiplegia 
in extra-dural hemorrhage, but are not infrequent in 
intra-dural hemorrhage, especially if that lacerates the 
brain tissue. The pulse is slow and hard, but toward 
the close of life becomes very rapid in extra-dural 
clots. In intra-dural clots it is more likely to be rapid. 

In both conditions slow, embarrassed, stertorous 
breathing and a rise of temperature may occur. 

Vomiting -is more frequent in extra- than in intra- 
dural hemorrhage. Changes in the pupils are re- 



170 



BRAIN SURGERY. 



garded as an imx^ortant symptom. Dilated pupils 
point to cerebral pressure, and the pupil on the side of 
the pressure is large and often fails to react to light. 
Jacobson holds that the inequality is less marked in 




Fig. 50.— Diagram of the Left Side of the Head to show the Situation of the 
Functional Areas of the Brain and their Relation to the Fissures of Rolando and 
Sylvius. The sjTnptoms produced by extra- or intra-dural clots will depend on the 
situation of the clot. 



intra-dural hemorrhage, but this statement is open tc 
doubt. 

A unilateral impairment of sensation on the side of 
the paralysis is found to indicate an extension of the 
clot backward ; while the development of aphasia when 
the clot is on the left side indicates an extension for- 



TREPHINING FOR CEREBRAL HEMORRHAGE. 171 

ward. The same would be true in intra-dural hemor- 
rhage, though there aphasia would he more likely to 
occur alone without hemiplegia. This is easily evi- 
dent by reference to Fig. 50. 

Disorders of the control of the sphincters and auto- 
matic movements are the last symptoms to be men- 
tioned by Jacobson. 

It is evident from this review that it maybe exceed- 
ingly difficult to differentiate extra- from intra-dural 
hemorrhage. If, however, a diagnosis of a hemor- 
rhage compressing the convexity of the brain is made, 
and it is evident that the case is becoming serious, it 
is usually advisable to trephine, and if the clot is not 
found outside the dura to seek it within. 

There are some cases of traumatism of the head 
which are followed by general signs of compression, 
but in which there are no local symptoms such as pa- 
ralysis or loss of sensation or aphasia to afford a guide 
to the surgeon. Where such local symptoms fail and 
where the original injury has left so little trace as not 
to point the way to an operation, trephining is ven- 
turesome, for the chances are by no means good of 
finding the clot. 

When such local and general symptoms of compres- 
sion develop, it is safe and proper before undertaking 
an operation to watch the patient for at least a week, 
being ready, however, to act promptly if the situation 
becomes alarming. The delay in the removal of the 
clot is not likely to do any permanent injury, and it is 
not at all impossible for the hemorrhage to cease 



172 BRAIN SURGERY. 

spontaneously or for a small clot to be completely- 
absorbed. Thus, in a case recently under my observa- 
tion, the patient, who had a severe fall without ap- 
parent cranial injury, lay for three days in a state of 
coma with left hemiplegia, then recovered conscious- 
ness, but for the following three days was entirely un- 
able to speak, though able to understand what was 
said to him, and had continual rhythmical movements 
of a restless character in his right limbs, but never- 
theless appeared to be gradually improving in his 
general symptoms. The left hemiplegia indicated a 
clot upon the right hemisphere, and the right-sided 
movements with aphasia indicated a clot upon the left 
hemisphere.' Operation was postponed from day to 
day as his symptoms gradually diminished in their 
intensity and severity, and it was finally abandoned. 
He made a good recovery and at the end of two 
months was out and about, perfectly able to talk and 
to control the movement of all his limbs. In a case of 
this character it is probable that small clots were ab- 
sorbed from both hemispheres, leaviug little or no ap- 
parent effects. 

Non-Traumatic Hemorrhage. 

In very few cases has trephining for the removal of 
clots been performed when the hemorrhage was not 
of traumatic origin. 

' Dunn, Jour. Amer. Med. Assoc, 1886, p. 75, has recorded a 
case in which regularly recurring rhythmical movements of the 
left side of the body were produced by a large, thin surface clot on 
tJie right hemisphere. 



TKEPHINING FOR CEREBRAL HEMORRHAGE. 173 

Lucas Cliampionniere ' describes the case of a man 
who after a sudden stroke of apoplexy remained par- 
alyzed upon the right side, the right arm being the 
limb which was chiefly affected and which was con- 
tractured, the right leg sharing in the paralysis but 
not being so severely involved. This patient had de- 
veloped epilepsy subsequently to his stroke of apoplexy 
and his attacks were largely in the paralyzed limbs. 
He w^as trephined over the middle of the motor area, 
and an encysted clot was found lying just in front of 
the fissure of Rolando in the middle third of the an- 
terior central convolution, and was removed. The 
next day the hand was no longer contractured, and 
when he was allowed to get up out of bed after the 
healing of the wound, he was found to be able to walk 
with more ease. One slight convulsion occurred two 
months after the operation, but at the time of the 
report of the case, six months after the operation, the 
paralysis had nearly passed away and no more con- 
vulsions had occurred. 

Michaux ^ also reports a case of spontaneous hemor- 
rhage, not traumatic in origin and successfully located 
and removed. This patient was suddenly taken with 
an apoplectic attack, his right arm and leg being com- 
pletely paralyzed ; the left face was also affected, he 
became comatose and had convulsions for three days 
and was evidently moribund. When Michaux oper- 
ated, three trephine openings were made over the fis- 

1 Brit. Med. Jour. , May 17th, 1890. 

2 La Semaine Med., Apr. 1st, 1891. 



i 



174 BRAIN SURGERY. 

sure of Eolando upon the left side and several ounces 
of clotted blood were removed. He gradually recov- 
ered consciousness, and at the time of the report, five 
months after the operation, he had practically recov- 
ered, though there was still a perceptible weakness in 
his right arm and he had some difficulty with his 
speech. 

In the following case, which I saw with Dr. E. F. 
Weir, the operation was undertaken without a posi- 
tive diagnosis, but with the hope of finding a clot. 
The history shows the result : 

Case XIX. Opejiing the skull for removal of a clot. — 
Area of softening found. 

F. J. E., male, aged 40, had general convulsions 
in April, 1891, without known cause. This was fol- 
lowed by a slight degree of motor aphasia. Three days 
later he had a second fit, after which he was almost com- 
pletely aphasic and had a slight paralysis of his right face 
and right arm. The paralysis gradually increased, so 
that by the end of a week his right leg was also slightly 
paretic. From that time until the present he has had a 
partial right hemiplegia with motor aphasia and agraphia, 
lie has had repeated convulsions ever since he was first 
taken ill ; the convulsions always begin by a tingling in 
the right hand and arm. Ophthalmoscopic examination 
showed the left optic disc rather pale and the vessels smaller 
than on the right side. The man had not suffered from 
headache or any general symptoms of brain tumor, but a 
loud bruit was heard over the left temporo-parietal region. 

The diagnosis in this case was somewhat obscure. It 
was thought possible that the original trouble might have 
been a hemorrhage on the cortex, and that an operation 
might remove an old clot and thus relieve both the paral- 
ysis and the convulsions, but the existence of the bruit led 



TREPHIXING FOR CEREBRAL HEMORRHAGE. 



175 



to the suspicion of an aneurism of the middle cerebral 
arterj' lying within the fissure of Sylvius. The operation 
was therefore an exploratory one and was so stated to the 
patient. 

Operation. — On October 28th, 1892, Dr. Weir opened 
the skull at the New York Hospital, using Horsley 's rotary 
electrical saw and removing a square piece of bone about 
two and one-half inches in each direction. A thin metallic 




Fig. 51.— Diagram of the Opening in the Skull in Case XIX. 



flat instrument, devised by Dr. Weir for the purpose, was 
passed through a small trephine opening and separated the 
dura from the bone, at the same time acting to protect the 
dura from the edge of the saw as it was carried along 
the various lines of incision. The operation of opening 
the skull in this manner was found to be more rapid than 
that of ordinary trephining. When the dura was divided 
and laid back the pia was found to be exceedingly oedema- 
tous ; when by pressure the serum had left the pia it was evi- 



176 BRAIN SURGERY. 

dent that the brain in the region of the third frontal convolu- 
tion and the lower half of the anterior central convolution 
had an abnormal appearance ; it was shrunken, flat on the 
surface, and yellow ; it was soft to the touch ; there was 
no clot over it, and there was no aneurism. It was evi- 
dent that the condition present was one of cerebral soften- 
ing, probably due to thrombosis ; it was also evident that 
nothing could be done to remedy this condition ; the wound 
was therefore closed, the plate of bone being replaced. 
This plate of bone had to be removed after two weeks, as 
it had not united to the skull; subsequently the scalp 
wound healed kindly and the patient was discharged from 
the hospital, unimproved, at the end of a month; during 
that month he had two fits in the hospital. 

In this case, therefore, the operation was entirely 
unsuccessful and the diagnosis of probable cerebral 
hemorrhage was incorrect. The case illustrates the 
difificulties attendant upon the diagnosis of cortical 
hemorrhage and also the safety of an exploratory 
operation, even when such an operation is very ex- 
tensive. 

Non -traumatic hemorrhages in the brain are very 
seldom open to an operation. The very large majority 
of sudden apoplexies are due to hemorrhages within 
the substance of the brain, or to embolism or thrombo- 
sis of large arteries. It is very rarely possible at the 
bedside to make an accurate diagnosis betv*^een cere- 
bral hemorrhage and thrombosis or embolism, and in 
spite of the many points of differential diagnosis laid 
down in the books the question is always an open one 
in the presence of any patient. There are a few cases in 
which the history seems to point clearly to a surface 



TREPHINING FOR CEREBRAL HEMORRHAGE. 177 

and not to a central clot. It is to be remembered that 
the motor centres in the cortex occupy a large area, 
and a clot forming upon the surface has its maximum 
of intensity over a small area, and therefore such a 
clot produces a greater paralysis in the one limb than 
in the others ; and as it increases in size the paralysis 
extends from the point of greatest intensity to other 
parts of the body rather slowly. Such paralysis is 
usually attended by some disturbance of tactile sensa- 
tion, and this is greater in the limb chiefly paralyzed 
than in the other limbs. A spastic contracture ap- 
pears very soon after the onset of the paralysis in the 
limb most intensely involved, and a progressive aphasia 
either of motor or of sensory kind is almost inevitable 
if the clot lies upon the left hemisphere of the brain. 
The stupor is deeper and more continuous in a sur- 
face hemorrhage than in others, and if the brain cortex 
is lacerated by a clot, unilateral spasms may follow 
the apoplexy. 

In a few cases of apoplexy such a history will point 
the way to surgical interference, but it must be con- 
fessed that in all cases of spontaneous hemorrhage in 
the brain surgical interference is purely exploratory. 
The period has not yet come, and it is questionable 
whether it ever will come, v^hen the diagnosis of a 
surface clot can be made with such precision as to 
warrant immediate trephining in apoplexy. 

When a hemorrhage has occurred within the cere- 
bral hemisphere, lacerating the tracts and destroying 

tissue, operation is out of the question ; for tissue once 
12 



mi 



178 BRAIN SURGERY. 

destroyed in the brain is not repaired by nature, and 
an attempt to remove a deep clot would result in the 
production by the surgeon of further laceration and 
serious hemorrhage. No one who has had any experi- 
ence in controlling the hemorrhage which arises from 
incision of the pia and cortex would advise deep inci- 
sions into the brain. 



CHAPTER V. 

TREPHINING FOR ABSCESS OF THE BRAIN. 

The Surgical Treatment of Brain Abscess. The Varieties of Brain 
Abscess. (1) Traumatic Abscesses. Surgical Indications for 
Trephining, General and Local. Report of Cases. (2) Abscesses 
Secondary to Ear Disease. Symptoms. Differential Diagnosis 
between Abscess, Meningitis, and Sinus Thrombosis. The Sit- 
uation for Trephining after Ear Disease. Illustrative Cases. 
Conclusions. 

Abscesses of the brain had been opened and drained 
by surgeons for many years prior to the beginning of 
modern brain surgery. It had long been known that 
abscesses of the brain develop subsequently to cranial 
wounds and fractures, and where these fractures were 
compound and comminuted it not infrequently hap- 
pened that an abscess would present at the external 
wound and be opened and drained by the surgeon. 
Sometimes exploratory incisions were made when such 
an abscess was suspected. 

Dupuytren and Detmold opened deep abscesses in 
the brain prior to 1850, and surgical journals contain 
many records of a similar nature from that time to 
the present. Many interesting facts bearing upon the 
doctrine of localization of brain functions may be 
gathered from the history of these surgical cases. 
Thus Hitzig records ' a traumatic brain abscess accu- 
^ Arch, fiir Psych. , iii. 



IHHI 



180 BRAIN SURGERY. 

rately limited to the lower third of the anterior cen- 
tral convolution and producing facial and hypoglossal 
paralysis, which occurred in a wounded French pris- 
oner in the year 1871. This was before Hitzig had 
made his experiments on the cortex of the brain which 
first located the motor centres. As we look back over 
many of these histories of surgical treatment of ab- 
scess, and study the character of the symptoms which 
were observed by the operating surgeon, these cases 
afford an interesting proof of the theory of localiza- 
tion. At the time they were treated, however, this 
theory was unknown, and the bearing of the facts 
observed upon the cerebral functions passed unnoticed. 
It is evident, therefore, that although the facts of local- 
ization throw much light upon the diagnosis of abscess 
of the brain, explain symptoms which were formerly 
obscure, and point more precisely to the seat of the 
disease than the mere traumatism, yet trephining for 
abscess is an achievement of surgery which antedates 
the present era. 

The Causes of Brain Abscess. 

Abscess of the brain develops usually under one of 
two conditions : (1) as the result of injury to the head 
with or without fracture, and (2) as a sequel of otitis 
media and suppurative processes in the orbit and nasal 
cavity. It is true that a few abscesses develop in the 
brain as a result of metastasis from gangrene of the 
lungs, from typhoid fever, from pyaemia, and from 
general tuberculosis, but these secondary abscesses are 



TREPHINING FOR ABSCESS OF THE BRAIN. 181 

SO rare and so manifestly removed from surgical treat- 
ment that we may disregard them.' 

Pathological Appearances. 

An abscess in the brain may present one of two very 
distinct and separate pathological appearances. It 
may be, first, a collection of pus within an irregular 
cavity without any distinct wall, but surrounded by a 
more or less pulpy broken-down and hemorrhagic area 
of brain tissue. The pus is usually green or brown 
and fetid. Such abscesses advance with great rapidity 
and rapidly lead to a fatal termination. This is clearly 
different from yellow softening of the brain, which is 
the result of necrosis following embolism and throm- 
bosis; though yellow softening was for a time con- 
founded by pathologists with brain abscess. Such an 
abscess requires prompt surgical treatment. 

The second form under which abscess presents itself 
is a collection of pus inclosed in a thick connective- 
tissue capsule lying within the white matter of the 
brain and quite distinct from the brain tissue. This 
form occasionally shows a tendency to progress rap- 
idly, but usually it lies in the brain like a foreign 
body and does not increase in size. Such an encap- 
sulated abscess may remain in the brain for many 
years, may give rise to no symptoms whatever, and 

* In Sajou's Annual from 1888 to 1892 inclusive there are records 
of 55 abscesses of the brain which have been operated upon. Of these 
28 occurred after injuries, 24 after ear disease, and 3 after typhoid 
fever ; 34 recovered, 21 died. Agnew in 1891 collected records of 18 
abscesses of the brain, all of which had terminated fatall3\ 



182 BRAIX SURGERY. 

may be a surprise to the pathologist at the autopsy. 
It is undoubtedly the sequel of an acute abscess 
which for some unknown reason has ceased to pro- 
gress. Nature provides for the disposal of the pus by 
shutting it up within a thick wall, and if it lies as it 
usually does in the temporo-sphenoidal or frontal lobes 
of the brain or in one hemisphere of the cerebellum, 
regions, as we have already seen, whose function is un- 
known, no symptoms will be produced. Such a patient 
lives, however, in constant peril, and many sudden 
deaths of unexplained nature are due to the sudden 
rupture of such an abscess into the ventricle or upon 
the surface. 

Occasionally some unknown cause starts up a series 
of cerebral symptoms in the person who has carried 
such an abscess in his head for years, and then this 
abscess increases in size and surgical aid may be re- 
quired. The existence of a thick wall does not pre- 
clude the possibility that an abscess is in process of 
rapid extension. 

It thus appears that the surgeon may be called upon 
to trephine in brain abscess under two very dissimilar 
conditions: (1) after a recent injury when cerebral 
symptoms appear early and progress rapidly, (2) in a 
patient with serious cerebral symptoms of an obscure 
character developing years after an injury or after an 
acute or chronic inflammation in the eye, nose, or 
ear. 



TREPHINING FOR ABSCESS OF THE BRAIN. 183 

Abscess folloiving Injury. 

In the first class of cases the surgeon will be guided 
partly by the site of the original injury, partly by the 
evident development of serious symptoms of brain 
compression following upon that injury, and partly by 
the facts shown by the local symptoms developed. 

In some cases the symptoms of abscess after an 
injury are clear. Thus in the well-known case of 
Fenger, ' where an abscess developed after a pistol-shot 
wound in the eye and the lodgment of the bullet in 
the frontal lobe, the exploration of the wound led to 
the discovery of the abscess,, which was apparently 
evacuated and healed. Some months later while going 
about the patient suddenly fainted, and subsequently 
developed serious cerebral symptoms. Fenger tre- 
phined the frontal bone, found an abscess two and 
one-half inches deep in the frontal lobe, and drained it 
successfully. The patient made a good recovery. 

In other cases there are local symptoms in addition 
to the purely surgical indications to guide the surgeon. 

Thus Elcan "" relates the case of a little boy who suf- 
fered from a compound comminuted fracture of the 
left frontal bone from which brain matter was ex- 
pressed. After a few days hemiplegia and aphasia 
developed and the boy became comatose. The frac- 
ture was laid bare and the bone elevated and portions 
removed. A hernia cerebri ensued and the symptoms 

1 Amer. Jour. Med. Sci. , July, 1884. 
'^Amer. Jour. Med. Sci., April, 1880. 



184 BRAIN SURGERY. 

of aphasia and hemiplegia remained, though his con- 
sciousness was clear. Four days later the wound was 
again examined, and during its manipulation eight 
ounces of pus were suddenly evacuated from an ab- 
scess which unexpectedly broke. Subsequently the 
aphasia and paralysis subsided, the wound healed, and 
the boy recovered. 

Stimson ' opened and drained an abscess in the pos- 
terior central convolution in the wrist centre about 
six weeks after the occurrence of a fracture above the 
right ear. The patient had recovered from the frac- 
ture, but had remained in a state of dull listlessness 
with severe and constant headache and a constant 
temperature of about 99°. From the time of the in- 
jury the left wrist and fingers had been paralyzed. 
In this case then the fracture, the cerebral symptoms, 
and the beautifully localized paralysis occurring in 
the left wrist all pointed to a cerebral abscess lying in 
the middle of the motor region of the right hemi- 
sphere. It is not surprising to-day that the abscess 
should have been found in this region, though in 1880, 
when Stimson operated, the facts of localization were 
so new as to make the operation almost an experiment. 

Janeway "^ has reported a case of abscess of the right 
occipital lobe following a blow on the left side of the 
head, in which two months after the injury trephining 
was done by Bryant. The patient had recovered from 
the injury but had suffered for some weeks from 

* Archives of Medicine, April, 1881. 

2 Jour. Ment. and Nerv. Dis. , 1886, p. 226. 



TREPHINING FOR ABSCESS OF THE BRAIN. 185 

headache, numbness, and weakness of the left arm and 
leg, which gradually mcreased, and from great mental 
dulness and apathy. When admitted to Bellevue he 
was somnolent, had temperature of 100°, pulse 106, 
left hemiplegia and left hemianopsia with choked discs 
and severe headache. He was trephined first over the 
parietal lobe of the right side, and then at the point 
of injury on the left side, but nothing was found by 
puncture of the brain. At the autopsy the abscess 
was discovered in the right occipital lobe. In this 
case it was impossible to determine whether the hemi- 
anopsia preceded or followed the hemiplegia, and 
some reliance was placed upon the surgical injury as 
a guide, though it was evidently on the side opposite 
to the hemisphere really affected. Had it been cer- 
tain that the hemianopsia was the first local symptom 
to develop, the trephining would have been done over 
the occipital lobe and the abscess would have been 
found. 

Wernicke and Hahn ^ have successfully located and 
drained an occipital abscess, being led to the diagnosis 
by the existence of hemianopsia. 

The following case illustrates the history of trau- 
matic abscess of the brain. 

Case XX. Traumatic abscess of the Brain. Trephin- 
ing — Death. 
I saw with Dr. Poore at St. Mary's Hospital, in 
1888, a little girl who soon after a fall on the left parietal 
bone with wound of the scalp developed cerebral symp- 

1 Wernicke : Virchow's Arch., Bd. 87, 5, 335. 



186 



BRAIN SURGERY. 



toms. For two weeks these appeared to be chiefly of a 
general nature ; then she developed right hemiplegia with 
much loss of sensation in the paralyzed limbs, and though 
too young and stupid to answer questions, it seemed that 
there was also a right hemianopsia. These symptoms in- 
creased in degree and the stupor passed into coma. The 
child was then trephined by Dr. Poore; the middle of the 
parietal bone being selected just posterior to the fissure of 



I 




Fig. 52. —The Situation of the Trephine Opening in Case XX. 



Holando. On exposing the brain there was no evidence 
of meningitis, and the cortex appeared to be normal though 
feeling somewhat soft to the touch. As the child showed 
signs of shock the operation was not carried further and 
the wound was closed. The child lived two weeks and 
then died. The autopsy showed the existence of an enor- 
mous abscess occupying the entire parietal and occipital 
lobes and extending downward into the temporal lobe in 
the white matter at least an inch below the cortex, and 



TREPHTNING FOR ABSCESS OF THE BRAIN. 187 

containing eight ounces of thick green pus contained 
in a capsule nearly one-fourth of an inch in thickness. 
This cai3sule would doubtless have been pressed inward and 
not punctured by a needle, had aspiration been attempted 
and the pus was too thick to have been drawn into any 
syringe. 

The appearance of the brain containing this abscess 
is shown in Fig. 53. 

It would be easy to cite many cases of this nature 




Fia. 53.— Photograph of the Left Hemisphere of the Brain CCase XX.) Contain- 
ing an Abscess. The cavity of the abscess is seen to lie in the parietal lobe ex- 
tending forward under the motor region and backward into the occipital lobes. 
The capsule of the abscess is also visible at the opening. 



where surgical indications and medical symptoms 
both point to an immediate injury and a growing 
abscess in the brain. In these cases the modern sur- 
geon is led to the diagnosis as much by his knowledge 
of surgery as by his knowledge of localization. From 
the medical standpoint, these cases require no further 
comment. 



188 BRAIX SURGERY. 

Abscess foUoii'ing Ear Disease. 

Another class of abscesses, either acute in their 
onset or of long standing, are those which develop in 
connection with or subsequent to otitis media. These 
abscesses form as the result of direct infection carried 
to the brain from the middle ear. 

Korner ' has shown that they occur with much 
greater frequency on the right side. Barr" in a col- 
lection of 76 such abscesses found 55 in the temporo- 
sphenoidal lobe, 13 in one cerebellar hemisphere, 2 in 
the pons, and 1 in the crus. Poulsen ' tabulates 13 
abscesses, of which 9 were in the temporal lobe and 4 
in the cerebellum. 

There are no local symj)toms produced by abscesses 
in the temiDoro-sphenoidal lobe that we can recognize 
unless the abscess grows to such a point as to invade 
the second or first temporal convolution on the left 
side, when sensory aphasia develops. There are no 
local symptoms produced by abscess in one hemisphere 
of the cerebellum unless the abscess grows to the point 
of invading the middle lobe or the peduncle upon the 
base, when stagg'ering begins. Thus it is evident that 
in a very large majority of the cases of brain abscess 
developing after ear disease the diagnosis must be 
based entirely upon general cerebral symptoms and 
not upon any local signs. These general symptoms 

J Zeitschr. f . Ohreuheilk. . Bd. xtI. , p. 212. 
■^ Brit. Med. Jour. . 1887, i. , 723. 
3 Arch, of Otol. , July, 1892, p. 346. 



TREPHINING FOR ABSCESS OF THE BRAIN. 189 

in the order of their importance are : (1) headache, 
usually general, occasionally worse on the side of the 
abscess; (2) mental irritability and mental dulness 
with slowness of thought, imperfect attention and 
memory, and occasionally delirium; (3) prostration, 
stupor, and appearance of illness wholly out of the pro- 
portion to the other symptoms ; (tt) temperature occa- 
sionally subnormal, showing little variation, rarely 
high and usually about 99°, and a pulse which is slow 
and sometimes intermittent; (5) tenderness of the 
head to percussion, and an elevation of temperature 
over the side of the head on which the abscess lies ; 
(6) chilly sensations and even an occasional chill; (7) 
disorder of the entire digestive system, nausea, vomit- 
ing, and constipation ; (8) facial paralysis of the periph- 
eral type on the side affected. (9) Optic neuritis may 
appear but is not a constant or even a frequent symp- 
tom Consciousness is usually preserved, but the pa- 
tient appears stupid, and as the abscess increases the 
stujoor may deepen into coma and general convulsions 
not infrequently occur. 

When such cerebral symptoms develop either after 
acute otitis media or subsequently to an old, long- 
standing, chronic otitis media (the latter is more often 
the case) , the question to decide is whether the patient 
is suffering from cerebral abscess, or from meningitis, 
or from thrombosis of the lateral sinus. The relative 
frequency of these three conditions after chronic otitis 
media is about the same. Thus in 36 cases recorded 
by Poulsen of cerebral complications of ear disease, 



190 BRAIN SURGERY. 

there were 13 cases of abscess, 12 of sinus throm- 
iDosis, 10 of meningitis, and 1 of hemorrhagic men- 
ingitis. 

In meningitis there is usually a more rapid onset and 
progress of the symptoms than in brain abscess. In 
meningitis the headache is associated with hyperses- 
thesia to sound and hght and touch all over the body, 
symptoms usually absent in cerebral abscess. In 
meningitis the temperature is high and the pulse is 
rapid, irregular, and intermittent. In meningitis there 
are occasional spasms and convulsions; strabismus 
appears and trismus is common ; and pain and rigidity 
along the neck are complained of as the disease ad- 
vances. Thus there are numerous points which dis- 
tinguish the two diseases from one another. 

Sinus thrombosis has also numerous points of differ- 
entiation from cerebral abscess. High fever with pyse- 
mic variations in its range and frequent chills ; a very 
rapid pulse, swelling and oedema over the mastoid pro- 
cess and oedema of the neck, swelling along the jugu- 
lar vein, which stands out like a hard cord in the neck, 
exophthalmos and even swelling of the conjunctiva, 
and marked venous stasis in the vessels of the scalp, 
are all symptoms not observed in cerebral abscess, but 
characteristic of sinus thrombosis. Choked disc ap- 
jjears early in the course of the case, while it is often 
wanting in cerebral abscess. 

Thus it is usually possible to differentiate cerebral 
abscess from the only two other cerebral complications 
of chronic or acute ear disease — and what is true of 



TREPHINI>"G FOR ABSCESS OF THE BRAIN. 191 

abscess after ear disease is also true of abscess after 
disease of the nose or orbit. 

It is thus evident that cerebral abscess produces 
marked general cerebral symptoms. If to these the 
local symptoms of aphasia or of cerebellar staggering 
are added, or if the general pressure of the abscess 
affects the function of the motor and sensory region, 
causing hemiplegia and hemianaesthesia of the op- 
posite side, the situation of the abscess may be esti- 
mated with sufficient certainty to guide the surgeon 
in his search. Even when the situation is uncertain, 
it is his duty to explore. For cerebral abscess is a 
hopeless condition portending certain death, and 
some risk may be taken in an attempt to save the 
patient. 

The best spot for trephining is one and three-fourths 
of an inch above and one and one-fourth of an inch 
behind the external auditory meatus, since at this 
point the temporo-sphenoidal lobe will be reached 
with greatest ease.' An attempt has been made by 
some aurists to approach the brain through the mas- 
toid cells, but this seems to me to be very bad practice, 
as the thickness of the bone is great, the position is 
too low to reach the brain, there is danger of entering 
the lateral sinus, and it is impossible to lay bare a 
large region of the brain. We have seen already that 
large openings in the skull are preferable to small 
ones, as they are less liable to be followed by hernia 
cerebri, and give the surgeon plenty of room, and 

^ See Birmingham : Dublin Jour. Med. Sci. , Feb. , 1891. 



192 BRAIN SURGERY. 

they are specially desirable in trephining for cerebral 
abscess near the base of the brain, for it may be nec- 
essary to explore the brain, in these cases with a large 
aspirating needle and subsequently to drain the ab- 
scess if it is found. 

Ballance,' in an admirable article on the operation of 
trephining for the removal of pysemic thrombi from 
the lateral sinus, gives a figure which I here repro- 
duce and which shows the relations of the external 
meatus to the brain, to the lateral sinus, and to the 
cerebellum; and the best positions for trephining to 
reach the various parts (Fig. 54) . 

It occasionally happens that abscesses developing 
after ear disease are so superficial that there is a 
marked tenderness of the scalp and bone over them, 
but, as a rule, abscesses lie very deep within the white 
matter of the brain, and to be reached and emptied 
the brain must be incised. Horsley has invented an 
ex2)loring instrument for this purpose which is very 
useful — a cylindrical speculum, long and pointed, and 
so divided that its sides can be separated gently after 
it has been thrust into the brain. Even with this in- 
strument the wall of the abscess may be pushed on- 
ward and not perforated. The pus is entirely too 
thick to be withdrawn by an ordinary hypodermic 
syringe. When the abscess has been evacuated it 
must be washed out and drained. It usually heals 
slowly, and constant care is necessary to prevent the 
occurrence of a secondary meningitis. 
1 Lancet, May 17th, 1890. 



TREPHINING FOR ABSCESS OF THE BRAIN. 193 




Fig. 54.— Lateral Aspect of a Small Adult Skull (Ballance). The illustration 
shows the relations of the lateral sinus to the outer wall of the cranial cavity and 
the position of the trephine opening (a) which should be made when it is deemed 
necessary to expose it. The base line (Reid's) passes through the middle of the 
external auditory meatus and touches the lower margin of the orbit ; it is marked 
out in eighths of an inch, as are also the perpendicular lines drawn from it. The 
measurements are made along the base line from the middle of the bony meatus. 
The drawing also shows the convolutions of the temporo-sphenoidal lobe, the Sylvian 
flssiu"e, and the position of the lower end of the furrow of Rolando (Rol.). ccx indi- 
cates the site of the tentorium as far as it is in relation to the external boundary of 
the skull. The anterior x shows the point where the tentorium leaves the side of the 
skuU and is attached to the superior border of the petrous bone, a, Trephine open- 
ing to expose sinus, five-eighths of an inch in diameter, its centre being one inch be- 
hind and a quarter of an inch above the middle of the bony meatus. This opening 
can easily be enlarged upward and backward and downward and forward (see the 
dotted Unes) by suitable angular cutting bone forceps. It is always well to extend 
it forward, so as to open up the mastoid antrum (c) and the gutter of the carious bone 
(if there be one) which leads from the antrum, tympanum, or meatus down to the 
bony groove. The position of the trephine openings which must be made for the 
rehef of inflammatory intra-cranial affections secondary to disease of the ear other 
than for sinus pyaemia have been added to the drawing for the sake of contrast and 
completeness. They are as follows : fo. Trephine opening to explore the anterior 
surface of the petrous bone, the roof of the tympanum, and the petro-squamous fis- 
sure, half an inch in diameter, its centre being situated a short inch (seven-eighths of 
an inch) vertically above the middle of the meatus. At the lower margin of this tre- 
phine hole a probe can be insinuated between the dura and bone and made to 
search the whole of the anterior surface of the petrous, c. Trephine opening for ex- 
posing the mastoid antrum, a quarter of an inch in diameter, and half an inch behind 
and a quarter of an inch above the centre of the meatus ; or a quarter of an inch 
above the centre of the meatus and a quarter of an inch behind its posterior border. 
The trephine should be directed inward and slightly downward and forward. When 
a superficial disc of bone has been removed it is well to repeat the operation with the 
gouge. A larger trephine may with advantage be employed, especially in adults, d, 
Trephine opening for temporo-sphenoidal abscess, half an inch in diameter. Situa- 
tion recommended by Barker, one inch and a quarter beliind and one inch and a 
quarter above centre of meatus. The needle of the aspirator is to be directed at first 
13 



194 BRAIN SURGERY. 

inward and a little downward and forward. Birmingham prefers one and tliree> 
fourths of an inch above in order to avoid the lateral sinus, e, Trephine opening 
for cerebellar abscess half an inch in diameter and one inch and a half behind and a 
quarter of an inch below the centre of the meatus. Birmingham prefers two inches 
behind and one inch below to avoid the occipital artery. The anterior border of 
the trephine should just be under cover of the posterior border of the mastoid 
process. The drawing shows that a trephine hole made in this situation is far 
away from the lateral sinus, and that the trocar and canula of the aspirator, if 
directed forward, inward, and upward, would hit an abscess occupying the anterior 
part of the lateral lobe of the cerebellum, which is the usual site of collections of pus 
in this part of the brain. 



Cases of Abscess of the Brain Successfully Opened. 

Stimson has reported the following interesting 
case : 

M. D., aged 39, took cold and developed an acute otitis 
media with discharge of pus from the left ear in Decem- 
ber, 1890. A month later he was admitted to the New 
York Hospital suffering from the chronic ear discharge 
and from severe pain in the left side of the head. He had 
had a convulsion two days before his admission and had 
been in a semi-comatose condition with intervals of rest- 
lessness and delirium since. On admission there was 
tenderness on pressure over the mastoid process but no 
redness or oedema. Pupils were normal; temperature 
102°. He remained in a semi-comatose state for six days, 
growing worse, and then Dr. Stimson operated. A curved 
incision was begun behind the base of the mastoid process 
and carried forward and upward, passing close to the ear 
for about four inches ; the flap was reflected, the bone ex- 
posed, and an opening three-fourths of an inch in diameter 
made through it with a chisel above and slightly behind 
the external auditory meatus in the posterior part of the 
squamous portion of the temporal bone. An incision 
through the dura gave exit to about three ounces of pus. 
The finger passed freely upward and backward. It was 
thought that an abscess had formed between the meninges 
and not in the substance of the brain, and that it had es- 
pecially compressed the posterior part of the temporal lobe 



TKEPHINING FOR ABSCESS OF THE BRAIN. 195 

in its inferior and outer surfaces. A drainage tube was 
inserted and the wound closed. 

A few hours afterward his mental condition had im- 
proved and pain was less. The improvement was progres- 
sive and the wound healed six weeks after the operation. 

Meanwhile his cerebral functions presented interesting 
features. During the first fortnight he seemed intelligent, 
but unable to comprehend his surroundings; he would 
listen intently when addressed and answer inarticulately, 
occasionally uttering a word that could be understood but 
which was usually unrelated to the question. It was not 
until the second week that he could name objects. He 
still failed to recognize faces at the end of the fourth wxek 
and was still unable to read. A month after the opera- 
tion he began to remember things, and then little by little 
the recollection of the past and of his illness returned; but 
he had no memory of his admission to the hospital or of 
his first month's stay. He spoke of the difficulty he had 
had in calling things by their right names, and said the 
difficulty still persisted although it was very much less. 
He also had difficulty in reading. He could write his 
name rapidly. Thare was no paralysis but his walk was 
feeble. He eventually recovered entirely. — N. Y. Med. 
Jour., May 30th, 1891. 

The following case, which is described by Von Berg- 
mann,' offers a good illustration of the history of an 
abscess secondary to ear disease: 

The patient had suffered from time to time during fifteen 
years from a purulent discharge from the ear, with occa- 
sional earache. The pain suddenly became more severe 
than usual and he began to have attacks of vertigo ; in the 
course of a few days his appetite failed; he began to feel 
sick and to have chills and fever at night. At the same 
time headache became very severe and kept him awake at 

1 " Die Chirur. Behandl. d. Hirnkrankh. , " p. 59. 



196 BRAIN SURGERY. 

night; this headache was general, but more intense upon 
the right side, which was also tender to percussion. When 
admitted to the hospital, a few days after these acute 
symptoms had begun, he gave the impression of being a 
very sick man ; was apathetic and stupid, and answered 
questions with difficulty and slowly; his skin was slightly 
yellowish and his tongue thickly coated ; his temperature 
was 99° and pulse only 50 ; there was a slight difference 
in the power and sensation of the extremities, his left 
arm and leg being somewhat weaker and less sensitive 
than the right ones. There was an occasional twitching 
in the right side of the face ; the pupils were equal and re- 
acted promptly ; the right ear was filled with granulations 
and was discharging pus; the hearing was much dimin- 
ished. The mastoid process was not swollen or tender, 
but percussion above the ear over the temporal lobe was 
very painful. 

The symptoms mentioned increased in intensity during 
the following week ; his pain became greater and his men- 
tal condition more stupid. Yon Bergmann then trephined 
above the ear, exposing a space 3 cm. square. The dura 
pulsated, and when it was divided the brain bulged into 
the wound. Incision into the brain did not at first reveal 
the abscess, but the third incision directed somewhat for- 
ward gave exit to 30 c.c. of fetid green pus. Exploration 
by the finger showed the abscess cavity with a thick wall. 
This was washed out with iodoform ether and drained by a 
tube 4 cm. long; the tube was surrounded by layers of 
iodoform gauze which protected the brain and membranes 
from contact with the pus, and the wound was thoroughly 
washed out before being dressed. 

The pulse rose from 50 to 88 as soon as the pus was dis- 
charged ; a daily change of dressing with a progressive 
closing of the abscess followed, so that on the ninth day 
the drainage tube was shortened, and by the end of the 
sixth week the wound had entirely healed. From that 
time for a year following the patient was in perfect health. 



TREPHINING FOR ABSCESS OF THE BRAIN. 197 

Another case is the following by Barker : ' 

Male, aged 33. Previous trouble in right middle ear, 
and epileptic attacks when young. In 1886 weakness and 
coldness in right leg; subsequently severe headache; 
tenderness over mastoid and right occipital regions. 
January 23d, 1887, two epileptic spasms within an hour; 
right side of body convulsed; subsequently unsteady gait, 
staggering to the left, and contraction of right pupil. 
January 25th, mastoid trephined in usual way; no pus 
found. Later, became semi-comatose, with paresis of left 
arm, and right pupil dilated. Diagnosis : Suppuration 
over or in arm and face centres of right side. February 
3d, 1887, operation. Trephine applied over fissure of 
Rolando ; dura bulging ; serum found at depth of an inch 
and a quarter; when an inch and a quarter behind ex- 
ternal meatus, pus found at considerable depth, and nearly 
half an ounce removed ; abscess cavity drained by rubber 
tube, after which as much more pus escaped. Serious 
collapse of patient; reaction finally established. Patient 
soon convalesced, made nearly complete recovery. 

Von Bergmann records seven other successful cases 
of operation for brain abscess quite similar in their 
history to his own.^ Other cases have been success- 
fully treated by Truckenbrod, Poulsen, Mayo, 
Pritchard, Cheyne, Paget, and others, and the 
records of the past three years show that a con- 
siderable percentage of cerebral abscesses secondary 
to ear disease, which have been accurately diagnosti- 
cated, have been reached by the surgeons and emptied. 
Inasmuch as this disease had been uniformly fatal 

' Brit. Med. Jour. , 1888, April 14th. 

^ These cases are by Schede (1) , Barker (3) , Greenfield, Macewen 
(2), Horsley. 



198 BRAIN SURGERY. 

before the treatment by trephining was introduced, 
success in its treatment must be reckoned as among 
the brilliant results of modern brain surgery. 

Abscess secondary to disease of the nasal cavity is less 
common than after disease of the ear. It is usually 
frontal in situation and produces no distinctly localiz- 
ing symptoms. 

Park ' has recently reported a case of abscess devel- 
oping in the frontal lobes after the removal of a polyp 
from the nose. 

The patient developed general cerebral symptoms about 
four weeks after the operation and became unconscious. 
In the comatose condition there were no localizing symp- 
toms whatever, and it was from inference rather than from 
any safer guide that Park decided to explore the frontal 
lobe. He raised a frontal flap and trephined above the 
orbit on the side from which the polyp had been removed. 
Exploration with a needle finally revealed an abscess cavity 
from which 12 c.c.of pus was evacuated. The cavity was 
drained with rubber tubing and the wound was closed and 
dressed. The patient died the following day. An autopsy 
showed the existence of a second abscess in the other 
frontal lobe corresponding in situation to the abscess 
opened. 

Conclusions. 

Whenever severe cerebral symptoms develop rapidly 
after an injury to the head which has broken the scalp, 
or after an operation upon the nose, orbit, or ear, or 
during the progress or subsequently to an otitis media 
or chronic nasal discharge, an abscess of the brain 
' Med. News, Dec. 3d, 1892. 



TREPHINING FOR ABSCESS OF THE BRAIN. 199 

must be thought of. If other conditions can be ex- 
cluded, and if the situation of the abscess can be de- 
termined either by a study of the local symptoms or 
by a knowledge of the cause producing it, an opera- 
tion should be undertaken at once. The earlier the 
surgeon is called in the better the chance of the 
patient. The opening in the skull should be large 
enough to allow of free exploration of the brain and 
to secure free subsequent drainage. The drainage 
should be kept up until the abscess cavity closes from 
the bottom. Every endeavor should be made to pre- 
vent the pus from coming in contact with the mem- 
branes. The wound should be dressed frequently and 
kept clean. The general condition of the patient 
should be attended to, so that every opportunity for 
recovery may be afforded. 



CHAPTER VI. 

TREPHINING FOR TUMOR OF THE BRAIN. 

The Frequency and Varieties of Tumors in the Brain. Analysis of 
Six Hundred Tumors. Tumors in Children Contrasted with 
Tumors in Adults. The Diagnosis of the Nature of the Tumor. 
The Diagnosis of the Situation of the Tumor. The Percentage 
of Brain Tumors Open to Operation. The Results of Operation 
for Brain Tumors. Analysis of Ninety-seven Cases. I. Cerebral 
Tumors. Selected American Cases. Personal Case. Tumor 
of Frontal Lobes. II. Cerebellar Tumors. Diagnosis. Difficul- 
ties of Operation. Three Personal Cases. Table of all Brain 
Tumors Operated upon. Conclusions. 

Until a recent date the interest in a case of tumor 
of the brain appeared to end with the diagnosis, for 
prognosis was hopeless and treatment except in tumors 
of syphihtic origin was useless. 

But with the advance in the power to diagnosticate 
the nature and exact position of tumors came the 
possibility of turning that power to a practical use. 
And the marvellous development of aseptic surgery 
opened the way to achievements in the removal of 
brain tumors more brilliant than in any other field. 
The work of Macewen, Durante, Horsley, Weir, Keen, 
and Park, and the later successes of Von Bergmann, 
Czerny, Lucas Championniere, Troissier, McBurney, 
Deaver Gerster, and others, have placed upon a sure 
and permanent basis the surgery of the brain. And 
in no department of thi^ field of surgery have the re- 



TREPHINING FOR TUMOR OF THE BRAIN. 201 

suits been more striking and successful than in the 
excision of new growths. 

These facts have lent a new interest to the study of 
brain tumors. It is essential to investigate their fre- 
quency, their varieties, their various situations, their 
structure, and their diagnosis, and thus to reach some 
estimate of the prospects of success in their treat- 
ment by the trephine. 

The Fr^equency and Varieties of Tumors of the Brain. 

Authorities agree that brain tumors occur with 
about equal frequency in childhood and in adult life. 
Gowers states that one-third of the cases occur in per- 
sons below the age of tw^enty, so that it would seem 
that children were somewhat more liable than adults 
to this disease. In the list of organic nervous diseases 
of childhood cerebral tumor stands high, being only 
exceeded in frequency by meningitis, infantile spinal 
paralysis, and cerebral hemorrhage. In adult life it 
does not hold as conspicuous a place, being mentioned 
after cerebral hemorrhage, embolism, and thrombosis, 
and being less frequent than locomotor ataxia and 
than paretic dementia. 

Some years ago I made a collection of 300 cases of 
brain tumor in children and youths, deriving the cases 
from Bernhardt 's and Steffan's collections and from 
the journals published prior to 1888. The table then 
prepared is here reproduced, as it demonstrates the 
varieties and most common situation of these tumors in 
childhood. 



202 



BRAIN SURGERY. 



To afford some information with regard to the 
points of difference between tumors in childhood and 
in adult life, I have now prepared a second table con- 
taining 300 tumors occurring in persons above the 
age of twenty. These have been collected from Bern- 
hardt's tables; from my own collection of American 
cases of cortical lesion; from Br am well's book, and 
from the critical digests by Bernhardt in Virchow's 
Jahresbericht from the years 18S8 to 1892 inclusive. 

Table II.— Brain Tumors in Children and Adults. 



Situation. 


Mi 


.2 

5 





il 






6 w 

a 3 

6b 


s 

6 

3 


1 


o 


1 


-3 
g 


I. Cerebral axis : 






































1. Basal ganglia and lat- 






































eral ventricles i 


14 


3 


3 


9 


5 


8 






1 


1 


1 


2 




1 


3 


5 


27 


34 


2. Corpora quadrigemina 






































and crura cerebri.... 


16 


1 


1 


2 


3 


2 




5 








1 






1 


7 


21 


14 


3. Pons 


19 


11 


10 




5 


1 


2 


1 








2 




3 


1 




38 


17 


4. Medulla 


2 






1 














2 








1 




6 


2 


5 Base 




3 




2 


1 
1 


3 

1 


1 


1 






1 
1 








4 

1 


1 

11 


s 


4 


6. Fourth ventricle 


1 




1 






2 






5 


II Cerebellum 


'IT 


S' 


15 


«^ 


10 


13 


J 


fi 







^ 








11 
3 


10 


OR 


45 




M 


'^ 


o 


^ 


5 












*> 




3' 




43 


17 


IV Cortex cerebri 


IS 


f)! 


fi 


in 


I 




H 




'i! 


1 


11 




13 


1o 


''1 


107 


V. Centrum ovale 


6 


2 


1 


11 


5 


1 


1 


4 


15 




1 


3 


1 




5 


4 


35 


51 




152 


41 


\S7 


54 


|34 


86 


5 


25 


30 


2 


10 


33 


2 


20 


30 


41 


300 


300 



The first columns are children's tumors; the second columns adults' tumors. 

It will be noticed in comparing these tables that the 
relative frequency of the different varieties of tumors 
differs in children and adults, tubercular tumors pre- 
ponderating in childhood, but being relatively infre- 
quent in adult life. 

Glioma and sarcoma appear to be about equally 
frequent in childhood, but in adults sarcoma is more 
frequent than any other tumor, glioma being the next 
in frequency. Carcinoma, as would naturally be ex- 



TREPHINING FOR TUMOR OF THE BRAIN. 203 

pected, is more frequent in adults than in children, so 
also is gumma. 

It is rather singular that so few gummata have 
been recorded in literature. It is my impression, de- 
rived from clinical observation, that gumma is the 
most frequent form of brain tumor occurring in 
adults. Eumpff in his book upon "Syphilis of the 
Nervous System" has been able to collect a very large 
number of gummata of the brain and has described 
this class of cases fully. That gumma may be ab- 
sorbed by specific treatment is a fact which the ma- 
jority of syphilographers hold and which, my own ex- 
perience confirms ; it is, however, denied by Horsley, 
who recommends operation for gumma as well as for 
other tumors. It seems to me that the infrequency 
with which gummata are recorded in literature as 
having killed the patient would indicate that, though 
these tumors may be frequent in occurrence, they are 
susceptible to medical treatment and do not prove as 
fatal as other tumors do. 

Cystic tumors of the brain may arise either in con- 
nection with glioma or glio-sarcoma or independently 
as the result of parasitic infection. Hydatid cysts, 
echinococcus, and cysticercus are very much more fre- 
quently met with in the German and Australian records 
than in English or American journals. Kiichenmei- 
ster, in an article on this subject, has collected 88 cases, 
but I have not included them in the table, as they would 
give an appearance of undue frequency of this disease, 
which would mislead. In America a cerebral cyst of 



204 BKAIN SURGERY. 

parasitic origin is a curiosity, and but few cases are to 
be found in our journals. Cysts which are merely the 
result of preceding softening or hemorrhage are not 
to be reckoned among tumors, as they do not produce 
symptoms of tumor. 

Primary carcinoma of the brain is a great rarity. 
Among the cases tabulated are four which invaded 
the brain secondarily, after beginning in the retina of 
one eye, a not infrequent form of the disease in child- 
hood; the remainder being secondary to carcinoma 
elsewhere in the body. 

In comparing this list of the relative frequency of 
the various forms of tumors with smaller lists, I find 
that the relative frequency is about the same in all 
lists ; and therefore I think that this may be consid- 
ered fairly reliable, though statistics are always to be 
looked at with care. 

The diagnosis of the kind of tumor present is always 
a matter of probability in any case ; and hence such 
a list has a certain diagnostic value. It will, of 
course, occur to any one in the presence of a child 
with brain tumor to inquire carefully into any history 
of hereditary tendency to tubercular disease, and to 
examine carefully for other evidence of tuberculosis, 
such as enlarged glands, scrofulous joint disease and 
phthisis, chronic diarrhoea, etc. Occasionally the tu- 
bercular tumor has been found, after death, to be 
the only manifestation of infection, but this is not the 
rule. Tubercular tumors are so frequently multiple 
that the occurrence of local symptoms pointing to 



TREPHINING FOR TUMOR OF THE BRAIN. 205 

more than one tumor will also point to tubercular 
tumors. The determination of the question as to the 
existence of tubercular disease is of the greatest im- 
portance, in view of the possibility of surgical interfer- 
ence. Supposing that a brain tumor is diagnosticated 
and is located in a place accessible by trephining : if it 
is thought to be tubercular is an operation justifiable? 
Such an operation may prolong life, but the disease 
may reappear in the brain or elsewhere. The opera- 
tion is certainly attended by greater danger than in a 
non- tubercular person. Yet the existence of tubercu- 
losis does not prevent the surgeon from attacking 
tubercular joints or tubercular testicle. Should it 
prevent his attacking a brain tumor? Von Berg- 
mann ' thinks that it should, affirming that it is im- 
possible to remove the cheesy masses from the soft 
brain coverings and tissue with the thoroughness that 
is possible in dealing with bones. He claims that the 
operation will be incomplete, and that a relapse is then 
certain. In support of this view is the fact that a 
tubercular tumor of the brain was recently removed 
at St. Luke's Hospital in this city by Dr. B. Far- 
quhar Curtis from a patient of Dr. J. A. Booth, 
but within three months it had recurred. English 
surgeons have taken a different view, and have re- 
moved successfully several tubercular tumors com- 
pletely without relapse. But further experience is 
certainly necessary before any rule can be laid down 
in the matter. The greatest drawback met with in 

' "Chirurg. Behandl. d Hirnkrankheiten, " p. 58. 



^06 BRAIN SURGERY. 

dealing with tubercular tumors by surgical measures 
is the possibility of the presence of more than one 
tumor, the failure to detect and remove more than 
one, and the consequent need of a second operation 
when the second tumor develops sufficiently to give 
rise to special symptoms. 

If there is no probability in a case of tumor that 
tubercular disease is present, the diagnosis of the kind 
of tumor present is difficult. 

Carcinoma of the brain, though in a few cases pri- 
mary, is usually secondary to carcinoma elsewhere. 
Should such a tumor be found in the body, especially 
if it should be found in the orbit and in connection 
with the retina, the diagnosis of the nature of the 
cerebral tumor can be made. Otherwise it cannot be 
thought probable. To remove a secondary cancer in 
the brain when the primary cancer remained would 
liardly be undertaken by any good surgeon. 

Gumma is the form of tumor most likely to develop 
in adults, but unless there is a distinct history of ac- 
quired syphilis with other sy^^hilitic manifestations, 
and unless nocturnal headache and insomnia are pres- 
ent, the diagnosis will be uncertain. The test of spe- 
cific treatment should be applied in every case. 
Horsley limits the duration of medical treatment to 
six weeks. I would urge that unless the tumor is far 
advanced a more thorough trial be given. If no re- 
sult in the amelioration of symptoms is obtained in 
three months it is probable that further treatment 
will avail nothing. 



TREPHINING FOR TUMOR OF THE BRAIN. 207 

Cysts in the brain of parasitic origin form very 
slowly, never destroy but always displace the brain 
tissue, and rarely, if ever, give rise to localized symp- 
toms. In a case of brain tumor in which the symp- 
toms are all general and not local the possibility of 
cyst should not be overlooked, and the child's history 
should be investigated in regard to any exposure to 
infection, the presence of tapeworm or of hydatid 
tumors elsewhere. There is no reason vfhy such cysts 
should not be removed. 

The remaining varieties of tumor — glioma, sarcoma, 
or glio-sarcoma — cannot ])e absolutely differentiated 
from each other. Occasionally sarcomata in other 
regions of the body may lead to the suspicion that 
there is one in the brain, but secondary sarcomata 
are relatively rare in the brain. Hence this point of 
diagnosis is not to be relied upon. Glioma and sar- 
coma may be equally slow in growth, may produce 
very marked symptoms or none at all, and do not 
differ markedly in their selection of situations in which 
to develop. Bramwell believes that glioma starts in 
the white matter and invades the gray matter. Zie- 
gler afSrms the contrary, and the cases here cited cer- 
tainly confirm the statement of the German patholo- 
gist; but from, a disputed pathological question no 
diagnostic conclusions can be drawn Nor does the 
mode of origin throve any light upon the differentia- 
tion of sarcoma and glioma, for both result from 
blows and falls upon the head with equal frequency. 

There is but one fact which may make a differen- 



208 BRAIN SURGERY. 

tiation possible, viz. , that glioma is usually very vas- 
cular, much more so than any other tumor. A tumor 
which is vascular varies very much in its size, being, 
as it were, erectile. Variations in size within the 
brain are impossible, but the corresponding condition 
to erection in such tumors is an increase of intracranial 
pressure. Variations of intracranial pressure mani- 
fest themselves, subjectively, by varying intensity of 
symptoms, and by the possibility of modifying symp- 
toms by means of agents which affect the blood pres- 
sure, and objectively by the state of venous congestion 
of the retina. Furthermore, in glioma, hemorrhages 
within or near the tumor sometimes occur, giving rise 
to symptoms of apoplexy. Therefore, in a case of 
tumor, great and sudden changes of intensity in the 
symptoms, accompanied by visible changes of circula- 
tion in the retina, and affected in one way or another 
by such measures as hot baths, cold douches to the 
spine, hot mustard baths to the feet, or free watery 
purgation, will indicate a vascular tumor, probably a 
glioma. And this diagnosis will be reinforced by the 
occurrence of attacks apoplectic in character in the 
course of the case. And yet there are cases of glioma 
in which the tumor is quite hard and encapsulated, 
and in which these symptoms will be wanting. 

But there is a practical application of these points 
of diagnosis regarding the vascularity of the tumor 
in view of surgical interference. The form of tumor 
most suitable for removal is the hard, encapsulated, 
non-vascular tumor. That is the usual form of sar- 



TREPHINING FOR TUMOR OF THE BRAIN. 209 

coma, and is occasionally the form of glio-sarcoma but 
not of glioma. A case, therefore, is much more suit- 
able for operation in which no vascular symptoms, such 
as those mentioned, are present, whether it be sarcoma 
or glioma. And, vice versa, a tumor showing marked 
vascular symptoms will not be a favorable one for 
operation, no matter what its variety or position. 

Passing now^ from the consideration of the varieties 
of brain tumor and their differentiation, let us look at 
the situation of the tumor. 

The Situation of Bi^ain Tumors. 

It is evident from Table II. that all parts of the 
brain maybe invaded by tumor, but that certain parts 
are invaded with special frequency both in childhood 
and in adult life. These parts are the cerebral axis 
and the cerebellum in children and the cortex in adults. 
By the cerebral axis is meant that part of the brain 
which includes the basal ganglia and internal cap- 
sule ; the corpora quadrigemina and crura cerebri ; the 
pons and the medulla oblongata (Fig. 55) ; and which 
lies upon the cranial floor and is therefore invaded by 
tumors lying upon the base of the brain. Of the 600 
tumors collected, 185 were in the cerebral axis. The 
diagnosis of such tumors is not difficult, as they usu- 
ally give rise to very numerous local symptoms, chiefly 
those of involvement of the cranial nerves. It is not 
my purpose to discuss these here : they may be found 
in all the recent articles upon the local diagnosis of 
cerebral disease. The point of interest is that no case 

14 



210 



BRAIN SURGERY. 



of tumor of the cerebral axis can be reached by the 
surgeon. The situation of the parts is such that a 
tumor in them is not near enough to the convex sur- 




FlG. 55.— The Cerebral Axis, Basal Ganglia, Crura, Pons, and Medulla, with the 
Cranial Nerves.— Allan Thompson. 



face of the skull to be accessible (see Fig. 56). And 
therefore, in estimating the number of the cerebral 
tumors in this collection which might have been the 



TREPHINING FOR TUMOR OF THE BRAIN. 211 

subject of surgical treatment, this class, constituting 
one-third of the number, must be at once excluded. 
Coming next to tumors of the cerebellum, we find 




Fig. 56.— Photograph (Fraser) of a Dissection showing the Situation of the 
basal ganglia, cerebellum, pons, medulla, and spinal cord, and their relation to 
the other parts. The entire cortex of the left hemisphere has been removed so 
as to expose the basal ganglia and the left cerebellar hemisphere. 

that they number 141. They are twice as common 
in children as in adults. Thus in a collection of 
American cases of cerebral tumor without res'ard to 



212 BRAIN SURGERY. 

age which I have made, I find that of 45 cerebral 
tumors 3 occurred below the age of nineteen, while of 
29 cerebellar tumors 11 occurred below the age of 
nineteen. It is, therefore, evident that children are es- 
pecially liable to develop cerebellar tumors. The re- 
sults of attempts at the removal of cerebellar tumors 
will be carefully considered further on in this chapter, 
but it may be stated here that they are most difficult 
to reach or to remove. 

Multiple tumors form the next class in the table, 60 
in number, and these must be at once dismissed as 
outside the field of operation at the present time. It 
may be remarked in passing that where numerous 
local symptoms are present in a case which cannot be 
explained by a single lesion, the diagnosis of multiple 
tumor is justifiable. 

The remaining classes are tumors of the cortex and 
tumors of the centrum ovale, not deep enough below 
the cortex to involve the basal ganglia, 56 in number 
in children and ITS in number in adults. Both these 
classes of tumors can be reached by the surgeon. 
There are no especial indications for their detection 
and, removal in children as distinguished from adults, 
hence they may be considered together. 

As to the differentiation of cortical from subcortical 
tumors, that is still impossible, tumors near the cortex 
giving rise to the same symptoms as cortical tumors. 
Let us now look at the situation of these tumors in 
the various parts of the accessible cortex, so far as the 
histories enable one to classify them. 



TREPHINING FOR TUMOR OF THE BRAIN. 213 

Table III. — Tumors Open to Operation. 



Cortex and 
Centrum Ovale. 


Tuber- 
cle. 


Gli- 
oma. 


Sar- 
coma. 


Glio- 
Sarc. 


Cyst. 


Carci- 
noma. 


Gum- 
ma. 


Not 
Stated. 


Frontal 

Central 

Parietal 

Occipital 

Temp, splien. . 


9 

3 

1 

27 


9 

11 

3 

? 

26 


13 

22 

~3 

4 

8 

50 


6 
1 

1 

8 


4 

i 

5 


5 
3 

2 
5 
3 

18 


4 

7 

2 
13 


9 
6 

1 

1 

17 



Of this total of 164 tumors near enough to the sur- 
face of the brain to have been reached by the surgeon ' 
there were 46 in which an operation was clearly indi- 
cated from the general and local symptoms, and there 
were 37 in which had the attempt been made the 
operation would probably have been successful. Thus 
out of 600 tumors 37 could have been removed, i.e., 
about 6 per cent. 

It would require too much space to give in detail 
the history of each of these cases and to discuss the 
reasons for and against an operation. Suffice it to say 
that this conclusion is reached by a study of the local 
symptoms which during life would have given distinct 
evidence of the situation of the disease, and by a con- 
sideration of the pathological condition found at the 
autopsy which demonstrated whether the removal of 
the growth during life could have been accomplished. 

Many tumors in this collection could have been 
diagnosticated and located, but could not have been 
removed had the attempt been made. Others could 
have been removed, but the symptoms did not point 

- The remaining 70 were inaccessible. 



214 BRAIX SURGERY. 

with sufficient clistiuctness to the situation to give an 
adequate guide to the surgeon. The majority of the 
removable tumors were encapsulated sarcomata lying 
on the cortex in the central region and giving rise 
to spasms and to paralysis. Three of the occipital 
tumors producing hemianopsia and five of the frontal 
tumors causing aphasia might have been removed. 
The large majority of the gliomata and of glio-sarco- 
mata were infiltrated in the brain substance to such 
an extent as either to have escaped detection at an 
operation or to have been impossible of excision. The 
same is true of the carcinomata. Many of the tuber- 
cular tumors were multiple, and when one might have 
been reached the others wotild have eluded diagnosis. 

There were several cases of tumors within the brain 
either in the optic thalamus or in one lateral ventri- 
cle, which demonstrate how both diagnosis and opera- 
tion might fail. In these cases the symptoms might 
easily have led to a diagnosis of cortical tumors in the 
motor area, but had an operation been undertaken no 
tumor would have been found. Such cases should 
serve as a warning. They teach that under the most 
careful examination diagnosis is never absolutely ac- 
curate, and that many operations must necessarily be 
exploratory. This latter fact, however, is familiar to 
surgeons, and need not prevent the progress of cere- 
bral surgery. 

It may be remembered that in a review of 100 tumors 
in the museum of Guy's Hospital. Dr. Hale White 
found 10 which might have been removed safely. His 



TREPHINING FOR TUMOR OF THE BRAIN. 215 

percentage, 10 per cent, is larger than my percentage 
— 6 per cent including tubercular tumors. Mills and 
Lloyd found 10 cases in their collection of 100 which 
could have been operated upon. Knapp found but 2 
cases in his collection of 40 cases, and he estimates 
that Y per cent of the 4S5 cases tabulated by Bern- 
hardt could have been removed. Dana states that 
5 cases in 29 under his observation could have been 
removed. If we add these together the result is 7 
per cent for operation. ' 

This conclusion appears to be very unfavorable to 
surgical interference in brain tumors. It is to be re- 
membered, however, that in many cases the patients 
were only observed in a late stage of the tumor, when 
it had grown to such a size that early local symptoms 
were obscured, as they are likely to be, by later symp- 
toms. And it is also to be remembered that at present 
the observation of nervous symptoms is more careful 
and accurate than in former years, and that many 
cases now come under observation at an earlier stage 
than formerly, so that the diagnosis can be made be- 
fore the tumor has made much progress. 

Turning now from these theoretical considerations, 
let us see what have been the results of experience in 
the removal of brain tumors. 

Analysis of Operations for Removal of Tumors. 

The number of cases of tumor of the brain in which 
surgical relief has been attempted up to the present 
^ See also Knapp : " Intracranial Growths. " 



Cerebellar. 


Total 


16 


97 


9 


35 



216 BRAIN SURGERY. 

time, so far as I have been able to find them in cur- 
rent Hterature, and including my own cases, is 97:' 81 
of these were tumors of the cerebral hemispheres; 
16 of them were tumors of the cerebellum. The re- 
sults of these cases are stated in the table given 
below : 

Table IV. — Table of Eesults of Operation for Brain Tumor. 

Cerebral. 

Total number of cases operated upon 81 

Cases in which tumor was not found 26 

Cases in which tumor was found but not 

removed 1 2 3 

Cases in which tumor was removed and 

patient recovered 39 3 42 

Cases in which tumor was removed and 

patient died 15 2 17 

It will be seen that the percentage of recoveries 
after the successful localization and removal of the 
tumor is 46 per cent. Considering how recently the 
facts of localization have been determined and how 
novel is the surgical procedure of operation upon the 
brain , this large percentage of successful results is both 
interesting and encouraging. It makes it imperative 
that every case in which a tumor of the brain is sus- 
pected should be studied with increased care, and that 

1 The literature is extensive. Recent important articles are as 
follows : Weir andSeguin, Amer. Jour, of Med. Sci., July, August, 
and September, 1888. Keen, Amer. Jour, of Med. Sci., November, 
1888. Park, " Surgery of the Brain, " Transactions of the Association 
of Amer. Physicians aud Surgeons, 1889. Von Bergmann, "Die 
Chirurgische Behandlung von Hirnkrankheiten, " 1889. P. C. Knapp, 
" Intracranial Growths, " 1891 ; the last contains tables of all cases 
up to June, 1891. Theodore Diller, the Pittsburgh Medical Review, 
Oct., 1892. Articles in Virchow's Jahresbericht and in Sajous' 
Annual. 



TREPHINING FOR TUMOR OF THE BRAIN. 217 

the question of operation should be thorouglily con- 
sidered. 

It seems best to distinguish broadly between tumors 
of the cerebral hemispheres and tumors of the cerebel- 
lum. The diagnosis between these two conditions is 
perfectly easy, and the risk of operation in the two 
conditions is so different as to demand their separate 
consideration. 

First. Cerebral Tumors. 

As shown in the table, 81 tumors of the cerebral 
hemispheres have been treated surgically. 

In 54 cases out of these 81 the tumor has been suc- 
cessfully located and removed from the brain. Thirty - 
nine of the patients recovered, 15 died. 

Of these 54 tumors 43 have been removed from the 
motor (central) region of the brain. It is in this re- 
gion that the location of a tumor can be most easily 
determined and in which few mistakes of diagnosis 
have been made. The occurrence of spasms or of 
paralysis limited to one limb, or extending from one 
to the others in a definite order, is diagnostic. In one 
of my own cases the motor symptoms were certainly 
of the greatest service in determining the location of 
the tumor. So too in a case reported by Erb in July, 
1892, in the Deutsche Zeitsclirift filr Nervenheilkunde. 
This case deserves mention on account of its unique 
history. 

The patient was a male and had suffered from the gen- 
eral symptoms of brain tumor, viz., headache, vertigo, 
vomiting, and optic neuritis, for some months. The de- 



218 BRAIN SURGERY. 

velopment of occasional spasms followed hj paralysis in 
the left arm and leg indicated the central convolutions of 
the right hemisphere as the probable position of the tumor. 
Czerny operated in November, 1890, and found the tumor 
to be an infiltrated glio-sarcoma, and removed a part of it, 
its complete extirpation being impossible. The patient 
recovered from the operation, was very much improved 
for eight months, and then began to suffer again from the 
old symptoms. In November, 1891, his condition had be- 
come so bad that it was thought best to repeat the opera- 
tion. The tumor was found to have grown again, and 
again a large part of it was removed. Again improve- 
ment was very striking, but at the date of the report, July, 
1892, a third operation upon this man was in contempla- 
tion, the symptoms having again appeared. 

It is evident that in such a case where the complete 
extirpation of the growth cannot be attained, ultimate 
success cannot be expected. Yet this case demon- 
strates the possibility of relieving the serious symp- 
toms and of prolonging life in, a disease formerly con- 
sidered incurable. The operation may be compared 
to that of removal of cancer of the breast, which pro- 
longs life even at the risk of recurrence. 

The location of the tumor in the remaining 23 cases 
was as follows: in the frontal region in 5, in the 
parietal region in 1, in the occipital region in 2. In 
the remainder the location was not exactly stated in 
the history. Occipital tumors can be so easily diag- 
nosticated by the existence of hemianopsia that it 
seems singular that but two have been removed . Parie- 
tal tumors give rise to sensory symptoms associated 
with motor symptoms, and when in the left hemisphere 



TREPHINING FOR TUMOR OF THE BRAIN. 211) 

they also produce symptoms of sensory aphasia of the 
variety known as word-bHndness or alexia. It must 
be confessed, ho vf ever, that the diagnosis of tumors in 
tliis location is much less certain than that of tumors 
in the motor zone. Tumors in the left temporal lobe 
also produce sensory aphasia of the variety of word- 
deafness. Mental changes and secondary motor symp- 
toms occur in tumors of the frontal region. They v^ill 
be more fully discussed in connection with one of the 
cases here recorded. 

In 25 cases the operation was unsuccessful be- 
cause the tumor was not found by the surgeon at 
the point at which it was supposed to lie, or be- 
cause the operation was undertaken for the relief 
of the symptoms caused by intracranial pressure and 
not with a view to the removal of the tumor (8 cases). 
In some of these cases the local symptoms were clearly 
insufficient to indicate the position of the tumor, and 
a cautious neurologist would not have advised an at- 
tempt to find it. In other cases the local symptoms 
were well marked and the diagnosis seemed clear, yet 
the tumor really lay at such a depth as to be inacces- 
sible, or was so infiltrated in the brain as to make its 
removal impossible. These cases must necessarily be 
counted as failures in the estimation of the percentage 
of success. Yet exploratory operation is not to be 
condemned, for we are dealing here with a hopeless 
disease, and it is proper to make an attempt to save 
the patient even though that seem to be desperate. 

It is evident, therefore, that tumors have been sue- 



220 BEAIN SURGERY. 

cessfullv diagnosticated and removed from almost all 
parts of the convexity of the cerebral hemisj^heres. 

It is impossible either to satisfactorily diagnosticate 
or to remove tumors lying on the median or basal sur- 
faces of the cerebral hemispheres, and no attempt at 
such removal has been made. 

It is impossible to give any detailed history of all of 
these cases. I select a fev American cases in which 
the diagnosis was clear both as to the nature of the dis- 
ease and as to its location, and in all of which the tu- 
mor was found at the operation. 

Selected Cases of Brain Tumors Removed. 

HiRSCHFELDER and MoRSE.— M., 33, in August, ISS-t, 
began to have j^ain in back of head and vertigo. Later he 
noticed dimness of vision and stiffness and weakness of 
left leg, then of left arm with occasional epileptic attacks 
and twitching of left side of face and left leg. 

When seen in February, 1SS6. he had frequent spasms 
of the left side, beginning in the arm, and a condition of 
left hemiplegia with loss of muscular sense in the left arm 
and anaesthesia of left face and general symptoms of brain 
tumor. 

Diagnosis was a tumor in middle part of posterior cen- 
tral convolution. 

Trephined February 15th, ISSH, by Dr. Morse. Bone 
thin. Dura found tense and white: when dura was di- 
vided brain bulged. The brain appeared to be hemor- 
rhagic and gliomatous. The growth. 2^ c.c. in size, was 
excised in part, it being difficult to separate it entirely 
from the healthy brain tissue. It was a glioma. 

Patient recovered from the shock of operation, but the 
paresis of the left side remained. The discharges from the 
wound became septic. The brain about the tumor was 



TREPHIXIXG FOR TUMOR OF THE BRAIN. 221 

much softened. He died on February 23d. — Pacific 
Med. Jour., April, 1886. 

BiRDSALL and Weir. — M., aged 44. Paretic symp- 
toms in limbs of right side, with diplopia, nausea, head- 
ache, etc. ; later, hemianopsia and neuro-retinitis. Diag- 
nosis of tumor in cuneus. This diagnosis was fortified b}^ 
further observation, and symptoms of inco-ordination ex- 
plained by its pressure on the cerebellum. Operation, 
March 9th, 1887, by Dr. Weir. On opening skull, dura 
did not pulsate, but was of dark color ; incision ; appear- 
ance of tumor of reddish color, covered with vascular con- 
nective tissue ; enucleation of same after its incision, and 
removal in two parts ; hemorrhage troublesome. Tumor 
found to be spindle-celled sarcoma ; greatest circumference, 
eight inches and a half; weight, 140 grammes. Five 
hours later, patient in collapse from secondary hemorrhage ; 
infusion of salt solution ; bleeding continued. Death nine 
hours after operation. — Med. Neivs, April 16th, 1887, p. 
423. 

Seguin and Weir. — M., aged 39. Spasms of right 
side and neck. In 1886 fell one day unconscious ; epileptic 
attacks preceded by aura in right hand and arm and right 
side of face. Diagnosis of tumor in left motor area. 
Operation, !N"ovember 17th, 1887, by Weir. Dura pro- 
truded slightly; appeared normal; extensively incised; 
brain seemed to protrude ; yielded deep resistance on pal- 
pation. Tumor, size of an almond, discovered at depth 
of an inch, not encapsulated, apparently infiltrating sur- 
rounding brain tissue. It was lifted out with a Volk- 
mann spoon. A small fragment, which had separated in 
process of loosening, was also separately removed. No 
hemorrhage from brain; wound drained and irrigated; 
discs of bone with several fragments replaced over the 
dura. Tumor found to be sarcoma, principally of round 
cells. Patient recovered; several months later was in 
good general condition ; better as regards paresis of face 
and hands; speech much improved. Five months later, 



222 BRAIN SURGERY. 

HO recurrence of growth. — Am. Jour, of the 3Ied. Sci- 
ences, July, 1888, p. 225. 

Three years later this growth recurred and the patient 
died. 

Keex. — M., aged 26. Fell from a window when 3 
years old, his head striking on a brick. A superficial 
TTOund was made, and no trouble was experienced until he 
was 23, when epilepsj^ developed, associated with aphasia 
and paralysis of the right arm and leg. Later there was 
recovery from much of this disturbance. Operation, De- 
cember loth, 1887. Keen removed a considerable area of 
bone and uncovered a tumor nearly three inches in length 
in its long axis. During the operation great trouble was 
experienced from hemorrhage, which was checked partly 
by hot water. Patient did well. For several hours on 
the third day symptoms of brain pressure were observed, 
and this was attributed to the presence of a large clot of 
greater size than the original tumor. This was removed 
by careful washing and all went well for ten days : then 
pressure symptoms were again observed. There was also 
some diarrhoea and a temj^erature of 104^°. The presence 
of pus was suspected and the wound reopened. No pus 
was found and a certain amount of hernia cerebri super- 
vened. It was inferred that the unfavorable symptoms 
were largely due to the diarrhoea, and two or three other 
similar attacks made this still more apparent. The hernia 
was finally overcome, partly by skin grafting. The 
wound was drained b}' bichloride gauze for eight weeks. 
It healed perfectly, but with a concave shape instead of 
convex. Four months later he was quite well, but had 
Iiad one epileptic attack. — Amer. Jour. Med. Sci., Oct., 
1888. 

" As to the final results of the case reported in the 
American Journal in 1888, the man is still living, in 
Lancaster, Pa. He has occasional epileptic fits, not 
nearly so often nor so severe as formerh', and he has 
had an interval as long as a year or thereabouts between 



TREPHINING FOR TUMOR OF THE BRAIN. 223 

his attacks. His eyesight has improved to a certain ex- 
tent, but not very much. His mental condition is, I 
think, a little better, but nothing of any moment. He 
has no headaches and locomotion is good." — Letter from 
Dr. Keen, Jan. 23d, 1893. 

Knapp and Bradford. — M., 32, had a blow on the 
head in 1868, followed the next day by convulsions. He 
was perfectly well until 1886, when he began to suffer 
from nausea, vomiting, and headache. In March, 1887, 
he had a spasm with extension and abduction of the left 
arm. About the same time there was loss of power in the 
left arm and leg and numbness of the left hand with in- 
creased reflexes and contracture. Optic neuritis then 
developed, and the convulsions continued and the paral- 
ysis increased. The convulsions usually began with a sen- 
sory aura in the left hand and a clonic spasm of the left 
wrist extending to the elbow. Sometimes the convulsion 
became general with loss of consciousness. In January, 
1888, headache had become so severe that he had to give 
up work, memory began to fail, and speech became slow. 
In November, 1888, Knapp found impairment of motion 
of eyes to the left, left hemiplegia with contractures, and 
hemiansesthesia most marked in the arm. Convulsions 
which were observed began in various parts of the arm. 
Trephined Dec. 28th, 1888, by Dr. Bradford, over the mid- 
dle third of the anterior-central convolution. Tubercular 
tumor 4 by 3 centimetres, weighing 35 grammes, was re- 
moved from the middle third of the two central convolutions 
on the right side. The patient died of shock in about an 
hour after. — Bost. Med. and Surg. Jour., April 4th, 1890. 

Church and Frank. — M., 39, began to suffer from 
convulsions in July, 1888, which continued until his 
operation. Each began with pain and spasm in the right 
index finger, partially involving the rest of the hand and 
passing up the arm. The extremity presented a flexed 
attitude and rapid clonic movement ; when the body was 
reached consciousness was lost and the patient would fall. 



224 BRAIN SURGERY. 

and the convulsion would become general and be followed by 
sleep. By January, 1889, the right hand had become con- 
tinuously painful ' and weak; he had become mentally dull 
and hemiplegic on the right side. He had constant severe 
frontal headache, tenderness to percussion on the left side 
of the head, but had no optic neuritis. He was trephined 
May 21st, 1889, over the middle third of the motor area 
on the left side. A small node was seen in the anterior 
part of the opening, and when a full exposure had been 
made a thickened, cicatricial-looking mass was found as 
large as a bone from which radiated filamentous processes. 
This was dissected away, causing a decortication of the 
brain over an area one and one-half of an inch in diameter. 
The wound was closed and drained and healed. During 
the following month his condition was stationary, the fits 
not recurring, but twitching of the arm being frequent. 
A rise of temperature then led to a reopening of the 
wound. The trephine buttons were found to be dead, and 
the cavit}^ in the brain was full of thick pus which was 
washed out. After this his condition improved. The 
wound healed, he recovered, and at the end of six months 
was in fair health. He was then having convulsions once 
in ten days ; had slight paresis in the right hand and arm, 
but was able to be about. — Amer. Jonr. Med. Sci., July, 
1890. 

" This case was under observation until July, 1892. 
He had so far improved that the attacks were two and 
sometimes three times as far apart. The pain in leg and 
arm was entirely gone. He was strong and had gained 
greatly in flesh. I do not expect, however, that he will 
ever be further improved, or be able to earn an independent 
livelihood."— Letter from Dr. Frank, Jan. 30th, 1893. 

Thomas and Bartlett. — Female; spasms beginning in 
fingers of left hand associated with numbness, advancing 
up the arm, occurred at intervals from January, 1887, to 

' This IS one of the few cases on record of '' central pain, " such as 
has been described by Edinger. 



TREPHINING FOR TUMOR OF THE BRAIN. 225 

March, 1889. After that the attacks became more frequent 
and extended to the left leg, and occasionally to the face, 
both arm and leg remaining paretic after the attack. 
These attacks continued until June, 1889. Headache 
was a constant symptom, but there was no optic neuritis. 
Diagnosis, a tumor in middle third of central convolu- 
tions. Operation June loth, 1889. On removal of the 
bone a pointed conical projection of bone three-eighths of 
an inch long was found projecting into the brain through 
the dura. Under this a large tumor was found, to which 
the dura was adherent, measuring 3| by 2^ by 1^ inches. 
This was removed. The convolutions under it were flat- 
tened and softened. Two days later left hemiplegia devel- 
oped, the patient became comatose and died. The autopsy 
showed the cavity filled by a clot and the adjacent brain 
much softened. — Haluiemannian Monthly^ May, 1890. 

Bremer and Carson. — M., 23,was well until 1887, when 
he began to suffer from spasms in the left arm which ex- 
tended to the neck and later, as they increased in frequency, 
to the left leg. This condition was followed by spastic con- 
traction with frequent spasms in the left foot and in the 
muscles of the left side of the neck, which later extended 
to the left arm, and the rigidity was attended by some 
weakness. Vomiting, insomnia, and great nervousness 
had developed by 1889, when he first came under Dr. 
Bremer's observation. There was slight beginning optic 
neuritis. The entire left side was paretic and the limbs 
were contractured, but could by effort be straightened. 
Every voluntary movement was opposed by simultaneous 
contractions of the antagonist. There was no anaesthesia. 
Spasms in the left side occurred frequently, beginning 
in the neck. The local symptoms of slowly increasing 
severity indicated a tumor in the right motor area at the 
centres for platysma and wrist in the post-central convolu- 
tion. Near this spot an old scar was found. He was 
trephined by Dr. Carson, March 2Gth, 1890, over the site of 
the scar. The dura bulged but did not pulsate. On 
15 



226 BRAIN SURGERY. 

exposing the brain it presented a reddish-brown appear- 
ance with torpid vessels, and the tumor could be outlined 
on three sides. It was very pliable, about the size of a 
^valnut, and was removed with a spoon. The tumor was 
a cavernous angioma. The cavity was drained and the 
wound dressed, and in a week the scalp had healed. The 
improvement after the operation was progressive. There 
was no return of the spasms, and the paralysis, which was 
somewhat more intense after the operation, gradually im- 
proved. Anaesthesia of the hand and arm was found after 
the operation and had remained up to the time of the re- 
port. — Aiiier. Jour. Med. Sci., Sept., 1890. 

" Although there was no return of the distinct spastic 
seizures resembling the Jacksonian type after the opera- 
tion, for the whole time that the patient remained under 
our observation at the Mullanphy Hospital (about sixteen 
months) the general improvement, i.e., the relaxation of 
the diffuse spasticity of nearly the whole muscular system, 
lasted only between three and four months, the general 
stiffness of the muscles reappearing and increasing as 
time wore on. At his own request he was transferred to 
a city institution, where his condition seems to have pro- 
gressivel}' grown worse, and where he died about a year 
later. The chief findings at the autopsy were : General 
miliary tuberculosis of the bowels; left kidney contracted. 
The brain was examined by Dr. Carson and myself. 
It showed the following pathological features: Right 
hemisphere (the one operated upon) was somewhat flat- 
tened at its upper margin, the dura firmly adherent to 
the brain substance below. On making a frontal section 
through the brain at the site of the operation, a subcorti- 
cal cavity was found at a depth of about an inch be- 
neath the adherent dura and corresponding approxi- 
mately to the middle third of the Rolandic region. 
This cavity was irregular in its outlines, about the size of 
a hickory nut. The surrounding brain substance was in 
a more or less softened condition and the whole brain was 



TREPHINING FOR TUMOR OF THE BRAIN. 2)17 

cedematous. The cavity corresponded to the place where 
the spongy cavernous mass was scraped out at the opera- 
tion. The presumable pathological process which took 
place after the operation seems to have been at first the 
formation of a blood cyst, which, after the manner of 
the apoplectic cysts, changed into one containing lymph. 
The emptiness of the cavity is explained, perhaps, by the 
thorough draining which the whole system underwent in 
consequence of the excessive diarrhoea. The principal 
lesson taught by the case is the fact established by other 
observers, that subcortical tumors (or their equivalents, 
cysts, e.g.) are apt to give rise to tonic spasms, 

" The bone button, which had been replaced after Mac- 
ewen's method, was found to have formed a solid bony 
union with the edge of the trephine hole, rendering the 
vault of the skull practically intact. The completeness of 
the surgical success in this particular has no doubt mili- 
tated against a better and more lasting result of the oper- 
ation. For had the button not been replaced, leaving 
only the scalp to protect the injured brain, this more elas- 
tic and yielding cover would have mitigated the pressure 
from below. A second operation, tapping for instance or 
scraping out of the presumable post-operative blood cyst, 
would also have been facilitated." — Letter from Dr. 
Bremer, February 4th, 1893. 

Wood and Agnew. — In his address before the Ameri- 
can Surgical Association in September, 1891, Agnew re- 
ported briefly that he had operated in a case of H. C. 
Wood in which a cyst occupj^ing the cuneus was exposed 
and emptied, but that the patient died in thirty-six hours 
after the operation, and at the autopsy a large sarcoma 
was found in the temporo-sphenoidal lobe, which had 
offered no localizing symptoms previous to the operation. 

The following case of my own is given in full be- 
cause it illustrates the general symptomatology of 
brain tumor and the local guides to the surgeon : 



228 BRAIN SURGERY, 

Case XXI. Sarxoma of the left frontal lobe — Mental 
and motor symptoms — Successful localization and 
removal — Subsequent death. 
C. S., aged J:0, a farmer by occupation, of good family 
history and of good general health until this illness (with 
the exception of specific disease acquired at the age of 22, 
but without subsequent manifestations), was suddenly 
seized with a convulsion in December, 1890, while driving 
a cart. He remembers a sudden feeling of dizziness and 
distress and then a turning of his head forcibly to the 
right side; he has no recollection of what followed, but 
learned that he had been found upon the road, had been 
picked up and carried home, where he remained uncon- 
scious for two hours and a half; he is not sure whether he 
had a general convulsion. On recovering consciousness he 
found his right side, including face, arm, and leg, slightly 
weak, and noticed some difficulty in talking ; this condi- 
tion gradualh^ subsided, so that in two weeks he was able 
to go back to his work, and felt in his usual health. This 
is the only convulsion or sudden attack of an}^ kind which 
occurred during his entire illness. 

But it is from this attack that his illness dates. The 
various symptoms which subsequently developed were very 
gradual in their onset, so that it is quite impossible to 
fix any dates for particular symptoms. During the six 
months from January, 1891, to July, 1891, he suffered 
occasionall}^ from headache and nausea, and in Jnlj began 
to notice that his sight was growing dim and that the 
headaches were becoming more and more frequent and 
intense. Between July, 1891, and January, 1892, the pain 
became localized over the forehead and top of the head on 
the left side ; it was not particularly worse at night, but 
at times was very severe. During this period he noticed 
a progressive dulness of thought, general hebetude, an 
aversion to work which was unnatural to him, and a slow- 
ness of mental activity which he described as increasing 
stupidity; and increasing difficulty in the use of Ian- 



TREPHINING FOR TUMOR OF THE BRAIN. 229 

giiage, SO that it took him longer to express his ideas, 
there being, however, no difficulty in articulation and no 
lack of words. 

He also noticed by the close of the year that his right 
side had become a little weaker than his left side ; that his 
hand was slightly awkward and that his leg felt a little 
heavy. The symptom, however, which caused him most 
distress was his gradually increasing dimness of vision, 
and it was on account of this that he came to New York 
from his home in Alabama. He was seen at the New 
York Ej^e and Ear Infirmary by Dr. Derby, who discov- 
ered a well-marked condition of optic neuritis in both eyes, 
more marked in the left eye: V. O. D. = -^, V. O. S. =; 
-|^. In right eye upper and inner quadrant of visual 
field wanting. Dr. Derby referred him to the Nervous 
Department of the Vanderbilt Clinic for confirmation of 
his diagnosis of cerebral tumor and also for treatment. 

When I first saw him at the clinic on January 14th, 
1892, the following symptoms were present: severe and 
constant frontal headache, located over the top of the 
head and more especially over the left side, about at the 
upper third of the coronal suture, and at this area, over a 
space about three inches in diameter, there was consider- 
able tenderness to percussion. There was no vertigo on 
rising or on change of position. There was a state of 
partial blindness due to the very well-marked condition 
of optic neuritis and decidedly worse in the left eye. 

There was a condition of mental dulness which was 
noticeable, and which he himself and a friend who accom- 
panied him insisted was wholly unnatural. This dulness 
consisted in a slowness of thought, which made him appear 
very stupid. It took him some time to appreciate the 
meaning of questions, and it was an effort to answer them. 
This effort was not due to any actual disturbance of speech, 
any loss of words, or any difficulty in pronunciation, 
though he complained that he could not talk as fluently or 
rapidly as heretofore. The condition was, therefore, in 



230 BRAIN SURGERY. 

no sense an aphasic one, but could only be spoken of as a 
slowness in mental processes. His comprehension was 
good and his conclusions were correct when he had time 
to think, but rapid mental action was impossible, and if 
insisted upon he became confused and would say he could 
not think. Hence he distrusted his own mental power, 
and said that he did not think that his judgment was as 
good as formerly. He was disinclined to occupy himself 
in any way, and sat in a listless manner saying nothing 
for hours at a time. He would often sleep in the day- 
time, though at night his sleep was often broken by his 
pain. It was not easy for him to hold his attention to 
any subject continuously for any length of time. His 
mental state might be termed a dull listlessness, and gave 
the impression that he was a sick man. 

Careful examination detected the existence of a slight 
right hemiplegia; his face was slightly flattened and slow 
in motion on the right side; his hand was somewhat 
awkward and clumsy, the power being 140 by the dyna- 
mometer, that on the left being 160. He dragged the toe 
slightly in walking, though his gait was not noticeable. 
He had great exaggeration of the knee jerks and marked 
ankle clonus. He complained of a feeling of numbness, 
both in the hand and foot, but there was no objective 
ansesthesia. 

Diagnosis. — 'From these symptoms a diagnosis was 
reached of a brain tumor. The situation of the tumor was 
not easily determined. The slight right hemiplegia indi- 
cated that it was in the left hemisphere of the brain, near 
to but not within the motor region. The hemiplegia had 
appeared long after the other symptoms, hence it was evi- 
dent that the motor zone had been reached only when the 
tumor had become large. The position of the headache 
and of the tenderness to percussion over the frontal region, 
and the existence of the mental symptoms described, ap- 
peared to indicate the frontal lobe as the probable situa- 
tion. This was confirmed by the absence of ansesthesia 



TREPHINING FOR TUMOR OF THE BRAIN. 231 

or of hemianopsia or of sensory aphasia, all of which 
conditions would have been likely to have been present in 
a tumor situated near to but behind the motor zone, in 
the parietal region. The mental symptoms were consid- 
ered of very great importance in the diagnosis of a frontal 
lobe lesion. 

A study of 23 cases of disease of the frontal lobes of 
the brain, made by me in 1884, showed that decided mental 
disturbance occurred in one-half of the cases. ' 

At that time the following conclusions were reached: 
" The form of mental disturbance in lesions of the frontal 
region does not conform to any type of insanity. It is 
rather to be described as a loss of self-control and a con- 
sequent change of character. The mind exercises a con- 
stant inhibitory influence upon all action, physical and 
mental, from the simple restraint upon the lower reflexes, 
such as the action of the sphincters, to the higher control 
over the complex reflexes, such as emotional impulses and 
their manifestation in speech and expression. This action 
of control implies a recognition of the import of an act 
in connection with other acts ; in a word, it involves judg- 
ment and reason, the highest mental qualities. By inhib- 
iting all but one set of impulses it enables one to fix the 
attention upon a subject and to hold it there. It seems 
probable that the processes involved in judgment and rea- 
son have for their physical basis the frontal lobes ; if so, 
the total destruction of these lobes would reduce man to 
the state of an idiot, their partial destruction would be 
manifested by errors of judgment and reason of a striking 
character. One of the first manifestations would be a 
lack of that self-control which is the constant accompani- 
ment of mental action, and which would be shown by an 
inability to fix the attention, to follow a continuous train 
of thought, or to conduct intellectual processes. It is this 
very symptom that was present in one-half of the cases 

' Starr : " Cortical Lesions of the Brain, " Am. Jour, of Med. Sci. , 
April, 1884. 



232 BRAIN SURGERY. 

collected. It occurred in all forms of lesion ; from injury 
by foreign bodies, from destruction by abscess, from com- 
pression and softening, due to the presence of tumors, and 
therefore cannot be ascribed to any one form of disease. 
It did not occur in lesions of other parts of the brain 
here cited. But its presence in such a large number of 
these cases warrants the suggestion that in cases of sus- 
pected lesion of the frontal lobe the mental condition of 
the patient, as shown by his acts of judgment and reason, 
should be carefull}^ examined, and a change of character 
or behavior accurately noted." 

Ferrier, in his Croonian lectures, 1890, again called at- 
tention to the occurrence of such mental symptoms in 
connection with diseases of the frontal lobes. 

Welt {Alienist and Neurologist, April, 1890) concluded 
from a study of eight cases under his observation that 
changes in character and disposition are characteristic of 
lesions in the frontal lobes. He says they may be the only 
symptoms present. 

W. Gilman Thompson {Medical News, May, 1890) has 
described changes in temperament and alterations in the 
intellectual sphere occurring in three cases of tumor of the 
frontal lobes under his observation. 

Schoenthal has also recorded a case diagnosticated as 
hysteria on account of the mental peculiarities and lack 
of self-control, in which a large tumor of the frontal lobe 
was found after death. 

Griffith and Sheldon {Jour, of Mental Science, 1890, p. 
223), in reporting a case of tumor invading the median 
surface and base of both frontal lobes in which mental 
symptoms were absent, call attention to the fact that men- 
tal sj'mptoms occur chiefly when the cortex of the convex- 
ity of the frontal lobes is invaded, and this statement is 
borne out by my ov/n collection of cases before alluded to. 

The review of these cases, therefore, pointed to the con- 
clusion that mental symptoms are likely to be produced 
by a tumor in the frontal region. 



TKEPHIXIXG FOR TUMOR OF THE BRAIN. 233 

The diagnosis of the nature of the tumor was some- 
what difficult. The existence of specific disease pointed to 
gumma and made it seem proper to try the effect of spe- 
cific treatment ; he w^as, therefore, put on inunctions of mer- 
cury and increasing doses of iodide of potassium, which 
was carried to the point of three hundred grains a day. 
This treatment was pursued without much apparent 
change in his condition. He then escaped from my obser- 
vation for months, but returned about the 1st of June to 
the clinic. 

It was then found that his headache was still severe, 
was still localized in the left side of the forehead. It was 
found that his sight was much worse, so that he was 
nearly blind in the right eye and could not read letters 
with the left eye. His hemiplegia was more marked ; his 
face was flatter on the right side, his arm and hand more 
clumsy, and there w^as a decided dragging of the right 
foot. He complained that his right leg was getting stiffer 
all the time and that it felt dead. He said that he had 
recently been having twitching in the right leg as often as 
two or three times a day. He also said that at times his 
hand became clinched without his power to resist it, but' 
he denied the existence of any clonic spasms. He had had 
some difficulty in micturition during the past months, it 
being impossible for him to control his bladder perfectly, 
the urine flowing unexpectedly. His speech was slower, 
and there was a noticeable tendency to the malposition of 
words in sentences, which, however, he noticed himself 
and corrected; he would often say "no" for "yes" and 
vice versa. His mental activity was evidently much 
weaker than it had been five months before. 

Under these circumstances it seemed evident that spe- 
cific treatment had failed of effect, and he was induced to 
enter Roosevelt Hospital and submit to an operation. 

Operation. — The operation was performed by Dr. 
McBurney on June 23d, 1891. Ether anaesthesia. A 
semi-elliptical incision was made in the scalp, outlining 



234 



BRAIN SURGERY. 



an area which measured about three inches in either di- 
rection, the attached base of the flap being below. The 
centre of the flap coincided with a point an inch and a 
half anterior to the fissure of Rolando opposite the junction 
of its upper and middle thirds. 

The tumor was believed to occupy the posterior part of 
the second frontal convolution, just anterior to its junction 
with the anterior central convolution. The hemorrhage 




Fig. 57.— The Opening in the Skull in Case XXI. 



caused by this incision was excessive, certainly treble the 
usual amount, and required a large number of pressure 
forceps and ligatures for its control. A button of bone 
one inch in diameter was then removed with the trephine 
from the centre of the area exposed by turning down the 
flap. This opening was enlarged with rongeur forceps 
downward and forward until it measured two inches by 
one and three-quarters (Fig. 57). 

The dura appeared to be thickened and was unnaturally 



TREPHINING FOR TUMOR OF THE BRAIN. 235 

pale, but pulsation seemed normal and no bleeding was 
noted. Profuse hemorrhage occurred from the veins of 
the diploe, and no little difficulty was met within its man- 
agement. The largest of these veins were occluded only 
by plugging their orifices firmly with small bits of sponge. 
The dura mater was then incised near the edge of the 
opening in the bone and turned down as a flap. It was 
quite adherent to the surface of brain beneath it, which 



;HiEllilS»lSitfOBlif!flKlfllff|iPii 



Fig. 58.— Photograph of a Sarcoma Removed from the Frontal Lobe. Case XXI. 
The measure above the tumor is divided into centimetres. 

was uniformly dark in color and very vascular. At the 
first inspection the surface seemed to be that of a much- 
congested ordinary cortical substance. It was, however, 
firmer in consistency than was normal, and a good-sized 
section was removed with the knife, and it was then clear 
that the whole area exposed was tumor tissue. At the 
end of the section removed a distinct capsule was met 
with, and following this with finger and blunt scissors, it 
was not difficult to completely enucleate the large tumor, 



236 BRAIX SURGERY. 

which extended in every direction heyond the edges of 
the opening already made in the skull. 

The tumor (Fig. 58) was oval in shape, measuring three 
and one-half by one and three-quarter inches. It was 
completely inclosed by a capsule, and after its removal a 
large cavity in the cortex remained. This cavity bled 
profusely at every point, the hemorrhage requiring for its 
control complete packing with iodoform gauze. The flap 
of integument was partially replaced and sutured at the 
sides only, a large loose antiseptic dressing being applied 
over all. 

Loss of blood and shock produced a marked effect upon 
the patient's general condition before the close of the oper- 
ation, and both rectal and hypodermic stimulation were 
actively applied, and after the patient's removal to bed he 
was given constant attention and every effort was made to 
improA^e his condition. After a large intravenous infusion 
of normal salt solution temporary marked improvement 
was noted, but the pulse soon failed again and death oc- 
curred about midnight, eight hours after operation. 

The exact situation occupied by the tumor was as 
follows : It involved the posterior part of the second frontal 
convolution, the adjacent portion of the first frontal and 
the upper half of the anterior central convolutions. The 
entire anterior central convolution must have been com- 
pressed to some degree, and indirect pressure must have 
been exerted upon the third frontal convolution below the 
tumor. The situation of the tumor corresponded, there- 
fore, very accurately to the diagnosis made before the 
operation, but the size of the mass was much greater than 
had been anticipated. After hardening in Mliller's fluid 
and alcohol it displaced fift}^ cubic centimetres of water, 
weighed four grammes, and measured two and one-half by 
two by one and three-quarter inches. The tumor was 
carefully examined by Dr. Eugene Hodenpyl, and was re- 
ported by him to be a true sarcoma, consisting of a large 
number of delicate blood-vessels and rather large, irregu- 



TREPHINING FOR TUMOR OF THE BRAIN. 237 

lar, but not branching, cells closely packed together with 
very little intercellular substance. 

An earlier operation, when the tumor was much smaller 
and the vascularity of the tissues much less, would very 
probably have been successful. It was proposed to the 
patient in February, four months before it was done. The 
delay, which he insisted upon, was more readily submitted 
to because of his specific history, which induced us to give 
him the benefit of the doubt and to try anti-syphilitic treat- 
ment. If Horsley's dictum had been accepted, namely, 
that gumma is not curable by medicine and should be 
operated for (a dictum, however, which the experience of 
others in several cases does not support), an earlier opera- 
tion would perhaps have been undertaken. The size of a 
brain tumor has undoubtedly much to do with determin- 
ing the amount of shock resulting from its removal. 

Summary. — In this case the diagnosis of the tumor 
of the brain was made from the general symptoms, 
headache, optic neuritis, and tenderness to percussion 
of the head, and from the local symptoms, mental dul- 
ness, slowness of speech, slight right hemiplegia with 
subjective numbness and occasional twitching in the 
paralyzed limbs. The situation of the tumor was de- 
termined by the slow onset of the hemiplegia, by the 
very marked mental symptoms, and by the location of 
the tenderness upon the head. Attention has already 
been called to the value of the mental symptoms in 
the localization of the tumor, and no further com- 
ment upon them is necessary. This is the first case, 
however, in which operative interference has been 
so distinctly directed by the existence of mental 
symptoms. 



238 BRAIN SURGERY. 

Secondly. Cerebellar Tumors. 

As shown in Table IV. (p. 216), 16 cerebellar 
tumors have been operated upon. In 9 cases the 
tumor was not found. In 2 cases it was found, but 
could not be removed. In 3 cases it was removed and 
the patient recovered. In 2 cases it was removed and 
the patient died. 

The diagnosis of cerebellar tumor is not difficult. 
The general symptoms of brain tumor are fully and 
rapidly developed, viz., headache; mental disturb- 
ance, irritability, and apathy; vertigo; vomiting; 
optic neuritis, with or without blindness, and possibly 
general convulsions. These present themselves in rapid 
succession because the situation of the tumor beneath 
the tentorium cerebelli is such as to obstruct the 
venous flow from the venae Galeni and the free inter- 
change of fluid between and through the ventricles, 
and to produce both general hydrocephalus and a 
stretching of the dura mater which are supposed to 
cause many of the general symptoms of brain tumor. 
It may be remarked that while headache is almost 
invariably present in cerebellar tumor and is often re- 
ferred to the back of the head, it may be felt at any 
part of the head, and is as frequently frontal or tem- 
poral as it is occipital. In many of the tumors here 
collected the headache was entirely frontal. The 
pain does not indicate, therefore, the seat of the tumor. 
Tenderness to percussion over the occiput is, however, 
a valuable sign of cerebellar disease. 



TREPHINING FOR TUMOR OF THE BRAIN. 239 

But, in addition to the general symptoms of tumor, 
there are local symptoms of great value. These are 
vertigo and cerebellar ataxia, or the staggering gait. 
The patient feels himself falling, staggers in walking, 
and often staggers toward one side with remarkable 
constancy. The occurrence of staggering indicates 
that the middle lobe of the cerebellum is either the seat 
of the tumor or is encroached upon by a tumor in the 
hemispheres. If it occurs quite early in relation to 
the general symptoms, it is the middle lobe in which 
the tumor began. If it occurs late, after many 
months of suffering, the tumor has started in one hemi- 
sphere, given rise to general symptoms, and has at last 
reached the middle lobe and produced the local symp- 
tom. The question at once arises, In which hemi- 
sphere has it begun? And here we are often in the 
dark. Patients are said to stagger, in walking, away 
from the side on which the tumor lies. An analysis 
of 20 cases in which staggering to one side was 
a prominent and constant symptom shows that in 
16 cases the patient staggered away from the side of 
the lesion and in 4 cases toward the side of the lesion. 
No definite conclusion as to the side of the lesion 
can be drawn from the direction of the staggering. 
If there is no tendency toward one side in walking, 
there may be a tendency to fall forward or backward. 
As yet, no assertion is possible as to the significance 
of this symptom, as it is impossible during life to de- 
termine whether it is due to irritation or destruction 
of tissue. 



240 BRAIN SURGERY. 

When these symptoms fail it is sometimes possible 
to determine which hemisphere is invaded by the 
tumor, by observing on which side cranial nerve 
symptoms, such as strabismus, facial or lingual anaes- 
thesia or paresis, deafness, or retraction of the head, 
appear. They usually come first on the side of the 
tumor, as this, by its presence, crowds the cerebellum 
down upon the base of the brain and presses on the 
nerves, or pushes it to one side and stretches the 
nerves. Paralysis of one fourth nerve, though diffi- 
cult to detect, is a valuable symptom, as it always 
occurs on the side of the tumor. 

By compressing one side of the pons or medulla a 
tumor may cause paresis or numbness, or increased 
reflexes in the opposite arm and leg, and these symp- 
toms may aid the diagnosis. 

The diagnosis being made, the question of operation 
arises: Can tumors of the cerebellum be removed? 
The cerebellum presents but one of its three surfaces 
to the skull, and there is, as yet, no means of deter- 
mining whether a tumor is near that surface or not. 
Any operation must, therefore, be primarily explor- 
atory. 

In case a tumor is seen upon the exposed surface, it 
may be removed. But great care should be observed 
in the manipulations about the cerebellar hemispheres 
in order that the medulla may not be compressed, or 
the pneumogastric nerves torn or stretched in the 
IDrocess. 

The figure (Fig. 56, page 211) shows how deep the 



TREPHINING FOR TUMOR OF THE BRAIN. 241 

cerebellum lies in the skull and how impossible it is 
to reach its upper surface or its anterior lower sur- 
face. It is not surprising, therefore, that the diffi- 
culty of thorough exploration of the cerebellum* has 
prevented the discovery of tumors in this part of the 
brain 

The following cases of cerebellar tumor, which have 
been diagnosticated by me and operated upon by Dr. 
McBurney, illustrate the symptomatology of the dis- 
ease and the difficulties of operation. 

Case XXTI. Fibrosarcoma of the cerebellum and 
pons Varolii — Staggering aivay from the side of 
the tumor — Operation — Death. 

Male, aged 30, was under my observation from Janu- 
ary, 1890, until December, 1891, when he died. He was 
referred to the Nervous Department of the Vanderbilt 
Clinic by Dr. Weeks. When first seen he was suffering 
from severe frontal and occipital headache ; from vertigo, 
which was much increased by moving the head suddenly 
or by lying down ; from tinnitus aurium ; from numbness 
in the left side of the face and in the mouth ; and from a 
very continuous feeling of drowsiness and dulness. These 
symptoms had developed gradually during the preceding 
three years ; and within a year he had also noticed double 
vision and a gradually increasing blindness. His friends 
said that his speech had become slow and thick. 

Examination showed a large, very dull, stupid man, 
with prominent eyes, the left one deviating outward, 
dilated pupils and marked nystagmus on lateral movement 
of the eyes. Dr. Weeks had found well-marked choked 
discs and a diminution of the visual fields. There was 
some slowness of speech which was accounted for by his 
mental dulness, there being no evidence either of aphasia 
or of paralysis of the tongue. There was no disturbance 
16 



242 BRAIN SURGERY. 

of sensation or of motion or of reflex action, and there 
was no ataxia in his gait. The existence of headache, 
vertigo, tinnitus aurium, nystagmus, diplopia, and choked 
discs established the diagnosis of a cerebral tumor, but no 
conclusion regarding its localization could be reached. 
That the tumor was not a gumma was admitted, as he 
denied all specific infection, yet he was put upon mercury 
and iodide of potassium on the supposition that he might 
have acquired the disease without his knowledge. 

During the year 1890 the symptoms continued and grad- 
ually increased in intensity, so that by the 1st of October 
he had become quite blind, with well-marked optic atro- 
phy ; and also deaf in the left ear, in which ear the tinni- 
tus aurium had been intense. By this time also local symp- 
toms had developed which gave an indication of the site 
of the tumor. There was a considerable degree of stag- 
gering in walking with a tendency to fall forward and 
toward the right, and a marked tendency to turn toward 
the right in walking. In addition there was some weak- 
ness in his right hand, the dynamometer registering only 
39 while it registered 60 in the left hand. There was no 
ataxia or disturbance of sensation in the limbs. There 
was no apparent difference in the power in the legs, but 
the knee jerk was exaggerated on the right side and a 
slight clonus was obtained on the right foot. 

The staggering was of the kind observed in cerebellar 
disease ; a gait like that of a drunken man, without falling 
but with every appearance that the balance was uncertain. 
The tendency to turn and to fall to the right was noticed 
on every occasion on which he was tested. 

Diagnosis. — The staggering indicated that the dis- 
ease was located in the cerebellum, and its direction to the 
right, while not considered sufficiently diagnostic to 
decide absolutely the question regarding which side was 
involved, was thought to point strongly to the left side. 
This supposition seemed to be confirmed by a study of the 
other symptoms. The patient had complained early in 



TREPHINING FOR TUMOR OF THE BRAIN. 243 

the disease of pain and numbness in the left half of the 
face, though at no time did examination show any anaes- 
thesia. He had also had much tinnitus in the left ear 
which had been followed by progressive deafness. His 
headache, which had at first been frontal, was later referred 
with much constancy to the left occipital region, and in 
speaking of it he habitually put his hand back of his left 
ear. The weakness of the right hand and the exaggera- 
tion of the spinal reflexes on the right side, taken in con- 
nection with left cranial nerve palsies, appeared to indicate 
some pressure on the left side of the pons and medulla. 

Thus the staggering to the right, the left cranial nerve 
palsies, and the right hemiplegia all pointed to a lesion 
in the left side of the posterior cranial fossa. 

The diagnosis was, therefore, made of a tumor on the 
left side of the cerebellum. The negative result of spe- 
cific treatment indicated that it was not a gumma, and 
the very slow progress of the case indicated that it must 
be a slowly forming tumor, probably sarcoma, as such 
tumors are more common than any other kind. 

During the following year, from October, 1890, to Novem- 
ber, 1891, the patient was seen occasionally, being appar- 
ently in a stationary condition. Finally, he was induced to 
enter the Roosevelt Hospital for operation. And then he 
was quite willing to submit, though knowing the dangers, 
because his life was a burden, for he was blind and partly 
deaf and suffering from severe headache, vertigo on any 
movement, and such exaggerated staggering that he could 
not go about. A careful examination in the hospital on 
December 1st, 1891, confirmed the existence of all the 
symptoms hitherto mentioned, but failed to elicit others. 

Operation by Dr. McBurney on December 3d, 1891. — 
Ether anaesthesia. A vertical tongue-shaped flap was 
marked out with the knife over the left half of the occi- 
pital bone. The upper free convex border of this flap cor- 
responded nearly to the superior curved line of this bone. 
The attached base was on the back of the neck about op- 



24-4 BRAIX SrRGEEY. 

posite the second cervical vertebra. The incision was 
carried down to the periosteum and all the coverings were 
removed in one flap. Experiments on the cadaver had 
satisfied the operator that the safest and most convenient 
method of entering the cerebellar fossa was by the use of 
the chisel and mallet. This method was adopted here, and 
an opening about one and a half inch m diameter was 
made through the thin bone, care being taken to be far 
enough away from the large venous sinuses. The dura 
mater was not diseased, but bulged very strongly through 
the opening in the skull in such a manner as to at once 
suggest intracranial pressure. Protrusion of cerebellar 
tissue was still more marked after- the dura had been 
turned back as a flap from over its sm^face. Otherwise, 
however, the surface of the cerebellum was normal in ap- 
pearance and palpation failed to give evidence of the exist- 
ence of tumor. It was found to be quite easy to introduce 
the finger for some distance into the skull on all sides of 
the cerebellar hemisphere, to thus examine a large part of 
its surface, and to distinctly palpate the lateral and vertical 
sinuses. But nowhere could the existence of a tumor be 
demonstrated. So much protrusion of cerebellar tissue 
existed that it was necessary, in order to close the opening 
in the skull at all satisfactorily, to shave off the excess, 
which was done with the less compunction as even the 
gentle manipulations practised had somewhat injured the 
delicate surface convolutions. Hemorrhage throughout 
the operation was \ery moderate and easily managed. The 
flaps of dura mater and overlying soft parts were then re- 
placed, fastened in all deeper parts with catgut, the skin 
wound being sewed completely with silk. A wet bichloride 
gauze dressing was applied over all and the patient was 
removed to bed in excellent condition. 

Convalescence was perfectly satisfactory, and on Decem- 
ber 9th, six days after the operation, the temperature 
being 90'' and the ])ulse 100, the dressing was changed for 
the first time. Primarv union was found throu2:hout the 



A 



TREPHINING FOR TUMOR OF THE BRAIN. 24:5 

whole extent of the wound, and all sutures were re- 
moved. 

During the following night the patient fell out of bed, 
and immediate examination revealed the presence of a large 
blood-clot beneath the skin flap. No other injury seemed 
to have resulted from the fall, but at 5 p.m. on December 
10th a chill occurred followed by a temperature of 103°. 

Difficulty in swallowing was then noted, and although 
at the end of two days the temperature fell to 99°, stupor 
gradually increased and involuntary evacuations of rec- 
tum and bladder began. The wound remained aseptic 
throughout, but the stupor deepened into coma and the 
patient died on December 15th with a temperature of 105°. 

The autopsy showed the presence of a tumor, a glio- 
sarcoma, whose limits were quite distinct from the cere- 
bellar tissue, though it was not encapsulated. 

It lay on the base and compressed the left hemisphere of 
the cerebellum and especially its anterior inferior (ventro- 
cephalad) surface, and also pressed upon the left half of 
the pons Varolii at its lateral part. The left crus was 
slightly indented by the tumor, and the fifth nerve had 
been flattened out by it without being so pressed upon as 
to be degenerated. The auditory and facial nerves were 
also compressed by the lower part of the tumor. 

The situation of the tumor was such as to have made it 
absolutely impossible to have reached it by operation, 
unless indeed the certainty of the situation of the tumor 
had been so complete as to justify full section of the cere- 
bellum. It was almost identical in situation and appear- 
ance with a tumor reported by Wollenberg in the Arch, 
fiir Psych., XXI., p. 791. 

Case XXIII. Glioma of the cerebellum — Characteris- 
tic staggering — Operation — Death. 
A little girl of 7 years of age had sufl^ered for a year 
from severe headache all over the head, but chiefly in the 
forehead, from severe vomiting and from gradually ad- 



246 BRAIN SURGERY. 

vancing blindness, due to a progressive optic neuritis. For 
three months before she was seen it had been difficult for 
her to walk, on account of a tendency to stagger and on 
account of dizziness which was undoubtedly due in part 
to nystagmus, which was observed early in the history. 
The staggering was very marked, so that during the last 
month she could not w^alk without aid. She did not ap- 
pear to stagger in any one direction constantly, but there 
was some tendency to fall backward and slightly to the 
left. She complained at times of earache in the right ear, 
but there was no evidence of cranial nerve palsy or of 
hemiplegia. 

Tlie diagnosis of cerebellar tumor in this case was 
quite evident, but the only clew to the position of the tu- 
mor was the tendency to stagger backward and to the 
left. It was thought probable that the tumor was in 
the vermiform lobe of the cerebellum, more likely upon 
the right than upon the left side. The absence of cranial 
nerve symptoms showed that it was not near the base. 
The operation was, therefore, undertaken. 

Operation. — The operation was done by Dr. McBurney 
on December 29th, 1891. Ether narcosis. A horseshoe- 
shaped incision with the convexity upward was made over 
the right half of the occipital bone. The upper part of the 
incision lay a little above the superior curved line of the 
bone, and the flap which was then turned down included 
all of the soft fissures excepting the periosteum. The base 
of the flap was left attached to the upper part of the neck. 

With chisel and mallet a considerable plate of bone was 
removed from over the centre of the cerebellar fossa, and 
the opening was then enlarged with rongeur forceps as 
much as was safe, having due regard for the venous si- 
nuses. The dura obtruded forcibly but otherwise appeared 
normal. A large flap of dura was then cut and laid back, 
revealing only normal cerebellar convolutions. Examina- 
tion of the sides and imder surface of the cerebellum gave 
no information. A probe was then passed some distance, 



TREPHINING FOR TUMOR OF THE BRAIN. 247 

about one and one-half inch into the brain substance, 
but no abnormal resistance was encountered. 

An aspirating-needle introduced about one-half inch 
from the median line and parallel with the base of the 
skull entered a cyst from which two drachms of clear 
serous fluid was withdrawn. 

A second introduction of the needle failed to detect the 
cyst and it was deemed unwise to make further explora- 
tion. The flaps were then replaced, being stitched deeply 
with catgut and superficially with silk. Hemorrhage 
during the operation was not troublesome, but before its 
close the patient showed the effects of shock. She rallied 
well, however, after rectal stimulation, and on the day fol- 
lowing operation seemed about as well as on the day before 
it, at intervals complaining of headache only. Two days 
later complaint was made of pain in the ears ; the wound 
was dressed and found to be aseptic. The temperature 
since operation had remained normal. 

On January 4th, six days after operation, vomiting oc- 
curred repeatedly, the pulse became weak, stimulation had 
no effect, and the patient died suddenly in a convulsion at 
midnight. , 

The autopsy revealed a large glio-sarcoma, two and one- 
half by two by one inch, which occupied the vermiform 
lobe of the cerebellum and extended into both hemispheres, 
chiefly into the right one. It lay just under the superior 
surface of the cerebellar cortex, but it nowhere reached 
the surface of the cerebellum. It projected downward, 
compressing the fourth ventricle. Its consistency was 
about that of the cerebellum, and in its centre was a cyst 
which had been evacuated by the operation. 

Case XXIV. Glioma of the cerebellum — Staggering 
to the left — Right cranial nerve palsies — Oper- 
ation — Successful reinoval of the ttimor. 
W. W., aged 10, of good family history, had been in 
perfect health until October, 1892, when he began to suffer 



248 BRAIN SURGERY. 

from headaches in the forehead, usually worse at night. 
These annoyed him occasionally during October and No- 
vember, and he then began to suffer from occasional ver- 
tigo and from attacks of very intense headache associated 
with vomiting and occurring every third and fourth night. 
It was also noticed that he was becoming rather dull 
mentally and very irritable. These symptoms remained 
during December and to them was added the symptom of 
occasional uncertainty in gait so that he would fall while 
runjiing. In the early part of January, 1893, he noticed 
some dimness of vision, and this was found by Dr. Kipp, 
of Newark, who examined him on January 21st, to be 
due to a well-marked condition of optic neuritis. At that 
time he was able to read large print without much diflS- 
culty ; but within a month he had become almost totally 
blind. During February the headaches, usually noctur- 
nal, increased in severity; were always associated with 
vomiting and vertigo, and he began to have ringing in the 
left ear and some deafness in the right ear ; his gait was 
noticed to be very unsteady ; his eyes were noticed to be 
prominent and to be in constant oscillation, and mental 
dulness became intense. 

He was referred to me by Dr. William Pierson, of 
Orange, N. J., on March 12th, 1893, with the preceding 
history. 

Examination showed a fairly nourished but pale little 
boy, with large head, rather prominent forehead, protrud- 
ing eyes which were in constant lateral oscillation and 
with which he could see nothing. At rest there was a 
manifest tendency of the right eye to turn inward, but he 
could look in either direction without apparent paralysis 
of the ocular muscles. All ocular movement was attended 
by marked nystagmus. Very extensive optic neuritis was 
found in both eyes ; smell was lost in the left nostril ; there 
was no apparent paralysis or anaesthesia in any part of 
the body or face, but upon forced effort with the hands a 
slight facial paresis on the right side was noticeable, and 



TREPHINING FOR TUMOR OF THE BRAIN. 249 

he was unable to whistle on account of inability to close 
the right half of the mouth. His hearing was decidedly 
defective in the right ear, both to nerve conduction with 
a tuning-fork and to the watch. His reflexes were dimin- 
ished in both knees. His gait was distinctly of a stagger- 
ing kind, and numerous tests revealed a marked tendency 
to stagger toward the left side. He described his head- 
aches as being agonizing and referred them entirely to the 
frontal region ; the skull was slightly tender to percussion 
over the vertex. The headache was much increased by 
a recumbent posture, so that for many nights he had sat 
up all night. 

Diagnosis. — The headache, vomiting, vertigo, mental 
dulness, and optic neuritis indicated clearly that the boy 
had a tumor of the brain. The cerebellar gait indicated 
its location in the cerebellum. The tendency to stagger 
to the left side, together with the deafness in the right ear 
and a slight weakness of the right side of the face and 
right abducens muscle, indicated that the tumor was upon 
the right side of the cerebellum and near to the base. 
An operation was therefore recommended. 

Operation. — On March loth Dr. McBurney operated 
at the Roosevelt Hospital in the presence of Dr. Pierson 
and Dr. Kipp. The occipital bone was exposed upon the 
right side by a horseshoe-shaped incision, and an opening 
was made in the bone below the superior curved line one 
and one-h-^lf by one and five-eighths inches in size. The 
opening was made by chiselling and by enlarging the open- 
ing by the rongeur. There was no adhesion of the bone 
to the dura. The dura was seen to be very blue, over 
two-thirds of the region exposed. On dividing the dura 
a cyst containing about a drachm of yellowish-green 
fluid lying upon the surface of the cerebellum was opened. 
When the dura was laid back and the wall of this cyst 
removed it was evident that a tumor was present, lying 
upon and in the cerebellum and extending toward the 
median line beyond the area exposed. It being impossible 



250 BRAIN SURGERY. 

to get at this tumor through the small opening made on 
account of the extreme bulging of the cerebellum, a por- 
tion of the cerebellar tissue was cut off and thus access^ 
was gained to the tumor. The tumor was. soft gray and 
very friable, having the consistence of jelly and being very 
vascular in structure. In attempting to remove it a cyst 
within it was ruptured and about a drachm of clear yellow 
fluid flowed out. By the aid of a sharp spoon the tumor 
was scraped out from within the cerebellum. After all 
accessible tumor tissue was removed, the cavity remain- 
ing in the cerebellum was an inch and seven-eighths in 
depth by about an inch in the other directions and ad- 
mitted freely the finger of the operator. There was no 
distinct wall or capsule to the tumor, but as far as possible 
all tumor tissue was taken away, leaving clear cerebellar 
tissue about it. Hemorrhage was arrested by pressure b}^ 
sponges introduced into the cavity, and when it was reduced 
to slight oozing the cavity was allowed to fill with blood 
and a rubber tissue drain was introduced. The wound 
was then closed, the dura and scalp being stitched with 
catgut ligatures and the skin united by silk. The entire 
operation was completed within an hour, but the shock was 
considerable and the boy required repeated stimulations 
before being removed from the table. 

He rallied well, however, and the next day was very 
comfortable. He had no headache, had not vomited, the 
nystagmus had ceased, and he had no trace of the facial 
paralysis. His knee jerks were higher than before the 
operation. His mind was clear. During the following 
week he continued to improve.^ 

In the following tables "" all cases of brain tumor 
thus far operated upon are tabulated. The first table 

' This case was added while this work was in press. The final 
result will be published later. 

^ This list is made up from Knapp's list and from a search through 
the current journals from January, 1891, to January, 1893. (r, re- 
covered ; d, died. ) 



TREPHINING FOR TUMOR OF THE BRAIN. 



251 



contains a list of the tnmois found at the operation, 
their situation, and the result. The second table con- 
tains a list of the cases operated upon in which the 
tumor was not found at the operation, but was dis- 
covered at the autopsy. 



Table V.— Tumors Successfully Removed. 



Durante, 

Macewen, . 

Barton, 

Booth and Curtis, 



Frontal. 
Lancet, Oct. 1, 1887, 
Brit. Med. Jour., Aug. 11, 1888, 
Annals of Surgery, January, 1889, 



Trans. N. Y. Neurol. 
1892 (recurrence), 



Jour. , December, 



Starr and McBurney, . Amer. Jour. Med. Sci., April, 1893, . . d 



Birdsall and Weir, 



Macewen, . 
Bennett and Godlee, 
Hirchfelder and Morse, 
Horsley, 

Macewen, . 
Seguin and Weir, 

Keen, .... 
Lucas Championniere, 
Ballet and Pean, 
Fitzgerald, . 
Rannie, 
Fischer, 

Thomas and Bartlett, . 
Limont and Page, 

Parker, 

Mercauton and Combe, 

Von Bergmann, . 



Occipital. 
Phil. Med. News, April 16, 1887, . . r 

Central. 
Lancet, May 16, 1885, . . . . r 

Med. Chir. Trans., 1885, Ixviii., 243, . d 
Pacific Med. Jour. , April, 1886, . . d 
Brit. Med. Jour.. April 23, 1887, 3 cases 
(1 recurrence) , . . . . r 

Lancet, Aug. 11, 1888, 3 cases, . . r 
Amer. Jour. Med. Sci., July, 1888 (recur- 
rence) , . . . . . , r 

Amer. Jour. Med. Sci., Oct., 1888, . . r 
Jour, de Med. et de Chir. , 1888, 298, . r 
Bull. Soc. Anat. de Paris, May, 1888, . r 
Sajous' Annual, vol. ii. , 1888, p. 36, . r 
Brit. Med. Jour. , May 19, 1888, . , r 
Verhand. Deut. Gesell. Chir. , 1888, p. 42 

(recurrence and died) , . . . r 

Trans. Amer. Inst. Homoeop. , 1889, 464, . d 
Brit. Med. Jour., Oct. 26, 1889 (recur- 
rence) , . . . . . . r 

Brit. Med. Jour., Nov. 30, 1889, . . r 

Rev. Med. de la Suisse Rom., August, 1889 

(unknown result) . 
Chirur. Behand. d. Hirnk., 1889, p. 137, d 



252 



BRAIN SURGERY. 



Table V.— Tumors Successfully Removed.— Continued. 



Clarke, 

Knapp and Bradford, . 

Church and Franke, . 

Oppenhein & Koehler, 
Graham and Chubbe, . 
Dunin, 
Lampiasi, 



Bremer and 

Castro, 

Eeynier, 

Doyen, 

Jeannel, 

Anderson, 

Pean, . 

Hitzig, 

Hitzig, 

Erb, . 

Poirier, 

Braman, 

Potempski, 

Llobet, 

Stieglitz, 



Carson, 



Central. 
Lancet, March, 1890, . . . . d 

Bost. Med. and Surg. Jour. , April, 1890, d 
Amer. Jour. Med. Sci. , July, 1890 (recur- 
rence) , . . . . . . r 

Berl. klin. Woch. , July, 1890 (recurrence) , r 
Aust. Med. Jour., July, 1890, . . . d 
Neurol. Central. , August, 1890, . . r 
La Psychiatria, 1890, 261, . . . r 
Amer. Jour. Med. Sci. , September, 1890, r 
Neurol. Central., Oct. 15, 1890, . . d 
LaSem. Med., April, 1891, . . . r 
LaSem. Med , April, 1891, . . . r 
La Sem. Med., April, 1891, . . . r 
Brit. Med. Jour., Mar. 14, 1891, . . r 
La Trib. Med. , June, 1893, . . . r 

Berl. klin. Woch., July, 1892, . . r 

Berl. klin. Woch. , July, 1892 (recurrence) , r 
Deut. Zeit. Nervenheilk. , July, 1890 (re- 
currence) , ..... r 

Eev. deChir., xii., 412, . . . . r 

La Sem. Med. , December, 1852, 2 cases, r 
Annals Surgery, December, 1892, . . r 

Rev. de Chir. , November, 1892, . . r 
N. Y. Med. Jour. , January, 1893, . . r 



Horsley, 
Verco, 



Region Not Stated. 
. Brit. Med. Jour., Dec. 9, 1890; 4 cases, 3 

died, . . . . . . d 

. Trans. Intercol. Med. Cong. , 1889, ii., 377, d 



Horsley, 
May, . 
Suckling, 
Maunsell, 



Cerebellum. 

. Brit. Med. Jour. , April 23, 1887, . . d 

. Lancet, April 16, 1887, . . . . d 

. Lancet, Oct. 1, 1887, . . . . d 

. New Zealand Med. Jour., 1889, ii., 151, . r 



Starr and McBurney, . Case XXIV. , page 247, 



Table VI. — Tumors Trephined for but Not Found. 
Frontal. 
Dana and Pitcher, . . N. Y. Med. Rec. , Feb. 9, 1889. 
Eskridge, .... Knapp, " Intracranial Growths, " ix. , 24. 



TREPHINING FOR TUMOR OF THE BRAIN. 



253 



Table VI. — Tumors Trephined for but not Found. — Continued. 

Temporal. 

Fraser Lancet, Feb. 27, 1886. 

Wood and Agnew, . . Univ. Med. Mag. , April, 1889. 



Putnam and Beach, 
Stoker and Nugent, 
Twynam, 



Sands, 
Sciamanna, 

Hammond, 
Ross and Heath, 
Seguin, 
Morse, 
Dobson, 
Gray, . 



Keecley, 



Kerr, . 
Mitchell Clarke, 



Horsley^ 

Seguin, 

Chisholm, 



Parietal. 
. Bost.Med. and Surg. Jour., April, 1890. 
. Dublin Jour. Med. Sci., October, 1890. 
. Aust. Med. Gaz., May, 1892. 

Central. 
. Phil. Med. News, April, 1883. 
. Bull, de R. Accad. Med. di Roma, 1885, 

xi., 75. 
. Jour. Nerv. and Ment. Dis. , June, 1887. 
. Lancet, April 7, 1888. 
. Bost. Med. and Surg. Jour. , Feb. 5, 1891. 
. Pacific Med. Jour., Feb., 1891. 
. Lancet, May 14, 1892. 
. Brain, 1892, Ixi. 

Pons. 
. Lancet, Sept. 21, 1889. 

Basal Ganglia. 

. Occid. Med. Times, February, 1890. 
. Brit. Med. Jour.. June 13, 1891. 

Region Not Stated. 

. Brit. Med. Jour. , Dec. 6, 1890, 6 cases. 
. Bost. Med. and Surg. Jour. , Feb. 5, 1890. 
. Aust. Med. Gaz. , May, 1892. 



Maudsley and Fitzgerald, . 
Amidon and Weir, 
Wyman, . . . . 

Springthorpe and Fitzgerald, 
Lampiasi, .... 
Bullard and Bradford, 
Knapp and Bradford, . 
Potempski, .... 
Stewart, .... 
Starr and McBurney, . 
Starr and McBurney, . 



Cerebellum. 

Lond. Med. Recorder, June, 1890. 
Annals of Surgery, June, 1887. 
Phil. Med. News, February, 1890. 
Aust. Med. Jour., November, 1891. 
Wien. med. Wochen. , May, 1887. 
Bost. Med. and Surg. Jour. , April, 1890. 
Knapp 's Case XXIX. 
Annals of Surgery, December, 1892. 
Amer. Jour. Med. Sci., Nov., 1892. 
Amer. Jour. Med. Sci., April, 1893. 
Amer. Jour. Med. Sci., April, 1893. 



254 BRAIN SURGERY. 

Conclusions. 

In any case which presents the general symptoms 
of brain tumor and in which during the progress of 
the disease such local symptoms appear as indicate 
that the situation of the tumor is in or near the 
cortex of the convexity of the brain, the operation 
of trephining is indicated. 

This operation is not to be undertaken hastily in 
any case, as it is important to try the effect of anti- 
syphilitic treatment in those patients who may have 
had syphilis, and to watch for other symptoms or for 
signs of multiple tumors in patients who may have 
tuberculosis. But if mercury and iodide of potassium 
fail to relieve the patient within three months, or if 
during that time the symptoms rapidly increase, the 
operation is not to be jDostponed. 

The chances of success are greatest in hard encap- 
sulated sarcomata and fibromata, and in these cases 
the history will show little variability in the symptoms 
during the progress of the disease. These tumors are 
usually on the surface and are easily removed. The 
chances of success are worth taking in glio-sarcomata 
and in soft infiltrating gliomata with or without cysts, 
as life may be prolonged by the operation and as sev- 
eral operations may be done successively if the tumor 
recurs. Such cases usually show much variability in 
the symptoms, as the tumors are vascular. The dan- 
gers are greater in their removal ; partly from hemor- 
rhage, partly from inability to excise them entirely 



TREPHINING FOR TUMOR OF THE BRAIN. 255 

without great loss of brain tissue and consequent 
shock. It is not to be forgotten that these tumors are 
liable to recur. The chances of success are fairly good 
in cysts of the brain, provided the wall of the cyst is 
excised or the healing of the cyst from adhesion of its 
walls can be secured by permanent drainage. To 
empty a cyst and close the wound merely invites a 
refilling with fluid and is useless. 

Secondary carcinoma and sarcoma are not favorable 
for operation, as the chances of their recurrence are 
great and the endurance of the patient is impaired by 
the primary disease. 



CHAPTER YII. 

TREPHINING FOR HYDROCEPHALUS AND FOR THE 
RELIEF OF INTRACRANIAL PRESSURE. 

Hydrocephalus. Tapping the Lateral Ventricles. Keen's Cases. 
Robson's Cases. Broca's Cases. General Conclusions. Methods 
of Operation. Trephining to Eelieve Intracranial Pressure. 

There are certain cases of disease within the cranial 
cavity which are attended by a distention of the lateral 
ventricles with serous fluid. The exact pathology of 
acute congenital hydrocephalus is not understood, but 
secondary acquired hydrocephalus may be due to an 
inflammation of the lining membrane of the ventricle, 
to tubercular meningitis, or to venous stasis produced 
by pressure upon the veins of Galen. Tumors situ- 
ated in the corpora quadrigemina, or in the crus cere- 
bri, or in the middle lobe of the cerebellum, which 
produce pressure upon these veins are commonly at- 
tended by a great effusion of serum into the lateral 
ventricles. Distention of the ventricles is not neces- 
sarily associated with oedema of the pia mater of the 
convexity. 

It is perfectly easy to recognize the existence of 
hydrocephalus occurring within the first three years 
of life by the characteristic distention of the head, and 
the imperfect or delayed closure of the fontanelles and 
sutures. When in later life the bones are so firmly 



TREPHINING FOR HYDROCEPHALUS. 257 

united as to resist any intracranial distending force 
the symptoms of an accumulation of fluid are very 
similar to those of brain tumor, viz., headache, optic 
neuritis, vertigo, vomiting, slow pulse, strabismus, and 
mental apathy. In the latter case it can never be de- 
cided clinically what is the cause of the symptoms, 
whether a brain tumor rapidly growing and of large 
size, or an accumulation of fluid in the ventricles of 
large amount, associated perhaps with a very small 
tumor. But in an}^ case it is a natural conclusion 
that the only possible relief for the patient is to be 
obtained either by arresting the accumulation of fluid 
or else by letting it out. The object of medical treat- 
ment by purgation, by mercurials, and by iodide of po- 
tassium in such cases is to arrest the secretion of fluid, 
and this rarely if ever succeeds. The surgical treat- 
ment by opening the skull and giving exit to the fluid 
is really the only one which promises much relief. 

For many years hydrocephalus has been treated in 
children by tapping the ventricle through the anterior 
fontanelle with an aspirating needle or by trocar and 
canula. The operation has been recorded as far back 
as 1667, it being said that Dean Swift, when a baby, 
was tapped in this manner. The usual method pur- 
sued has been to introduce the needle through the 
anterior fontanelle at one of its lateral corners, to 
press the needle or trocar deeply into the brain, and 
thus reach the anterior horn of the ventricle through 
its roof. This procedure is still practised, and several 

successful cases were reported as late as 1891 by 
17 



258 BRAIN SURGERY. 

Tordoff/ Illingworth/ Unverricht ' and Yinke/ The 
procedure is not one without danger and many deaths 
have been recorded. Thus Lawson ' and Smythe ' lost 
patients upon whoro they had operated, by a shpping 
of the canula and laceration of the brain. There is a 
lack of precision in this method of treating hydro- 
cephalus which condemns it in the eyes of many sur- 
geons. 

The operation of trephining the skull and making 
an opening into the lateral ventricle, inserting a tube 
and establishing a permanent drainage, was suggested 
by Wernicke in 1881, and again by Zenner in 1886, 
and again by Keen in 1888.' Von Bergmann, unbe- 
known to Dr. Keen, had attempted to tap a ventricle 
by opening into the anterior horn in July, 188Y; he 
had succeeded in reaching the ventricle, but the case 
proved fatal on the fifth day. The first operation 
performed in this country was done by Dr. Keen on 
January 11th, 1889.' The patient was a boy 4 
years of age, who had acute hydrocephalus and was 
rapidly developing blindness. It was supposed that 
the hydrocephalus was due to a tumor of the cerebel- 
lum pressing upon the strait sinus, a suspicion subse- 
quently confirmed by autopsy. Keen was led to under- 

1 Brit. Med. Jour., Apr. 18tb, 1891. 
-Brit. Med. Jour., Apr. 4tli, 1891. 

2 St. Petersburg med. Wochen., Oct. 5tli, 1891. 

^ Weekly Med. Review, St. Louis, Feb. 28th, 1891. 
^Brit. Med. Jour., Mar. 21st, 1891. 
6 Brit. Med. Jour., Mar. 28th, 1891. 
' Med. News, Dec. 1st, 1888. 
8 Med. News, Sept. 20th, 1890. 



TREPHINING FOR HYDROCEPHALUS. 259 

take the operation of tapping the ventricle and thus 
relieve the condition of intracranial pressure by the 
fact that in a previous case, where he had made an 
exploratory trephining for supposed abscess in the 
temporo-sphenoidal lobe and had introduced a drainage 
tube, the autopsy had shown that the presence of this 
drainage tube had not produced any inflammation of 
the brain. The operation upon the boy was made by 
trephining at a spot one and one-fourth inch above 
and one and one- fourth inch behind the left auditory 
meatus, and by puncturing the brain with a hollow 
needle which was directed toward a point two and 
one-half inches above the opposite meatus. At a 
depth of about one and three- fourths inch, resistance 
to the passage of this needle suddenly ceased, and the 
cerebro-spinal fluid began to escape; three double 
horsehairs were then passed into the ventricle and 
the tube was withdrawn. The drainage thus estab- 
lished was kept up for fourteen days, when the horse- 
hairs were replaced by a rubber drainage tube. On 
the twenty-eighth day after the operation, the symp- 
toms returning, a corresponding operation was per- 
formed upon the right side and the drainage tube was 
passed directly into the right ventricle. On the thirty- 
second day the ventricles were washed out from side 
to side with a warm boric acid solution, eight ounces 
being run in, and two ounces only escaping. The 
child was very restless at the beginning of this pro- 
cedure, but as it was done he said that ''it felt good." 
Irrigation was continued subsequently at intervals, 



260 BRAIN SURGERY. 

never producing any ill effects, but the child died on 
the forty-fifth day. The autopsy showed a sarcoma 
in the cerebellum and a distention of the ventricles 
with fluid ; the sinus through which the rubber tubes 
had passed was not surrounded by an inflammatory 
zone. Though the brain had been punctured in many 
directions at the operation in the attempt to find the 
tumor, no trace remained of these punctures at the 
time of the autopsy. 

Keen's second patient was a boy Si years of age, 
who had been a subject of hydrocephalus since the age 
of 4 months. He was an imbecile and epileptic. On 
March 5th, 1889, the left ventricle was tapped in the 
same manner as in the previous case, and drainage by 
horse-hairs was established. Four days afterward a 
drainage tube was inserted in place of the horsehairs, 
an opening on the opposite side being made. As the 
escape of fluid then appeared to be too free the tubes 
were plugged up. Then convulsions began, and it 
was concluded that too much, fluid had escaped, so 
warm water was allowed to run into the ventricle 
when the spasms ceased ; eight times the convulsions 
returned and each time were they arrested by the in- 
troduction of an ounce of warm fluid. The child then 
died. The autopsy showed great hydrocephalic dis- 
tention but no inflammation about the tubes. 

Keen's third case was one of tubercular meningitis 
with unilateral acute hydrocephalus of the left ventri- 
cle. The foramen of Monro was closed and the uni- 
lateral distention had produced right hemiplegia. The 



TREPHINING FOR HYDROCEPHALUS. 261 

left ventricle was tapped through the arm centre and 
fluid evacuated, but the child died about four hours 
later. 

In his article recording these cases Keen refers to two 
cases reported to him by letter by Mayo Robson. 
These cases were as follows : 

A girl 10 years old, without preceding illness, began to 
have pain in the left ear and was feverish, December 19th, 
1888. In three days a discharge followed, which gradu- 
ally lessened, but was still present a month later when 
admitted to the hospital. There had been also rigidity of 
the neck and twitching of the right angle of the mouth. 
No vomiting ; slight mental disturbance. On admission 
to the hospital January 19th, 1889, temp, was 105°; she 
complained of pain in the left side of the head ; there was 
paresis of the right arm and leg, which gradually devel- 
oped into complete hemiplegia and aphasia. Optic discs 
inflamed. Robson trephined February 7th, 1889, over 
the arm centre ; the dura was found healthy. On expos- 
ing the brain it did not pulsate, and seemed to be com- 
pressed. An exploring needle was passed deeply in various 
directions in the hope of reaching pus, but failing to find 
any the needle was pushed into the lateral ventricle and a 
half ounce of clear fluid was drawn off. After this pulsa- 
tion returned in the brain. The wound was closed, no 
drainage being employed. On the next day there was 
slight power in the arm, soon after in the leg, and on the 
third day she could answer simple questions. Within a 
month the hemiplegia was gone, and six months later she 
was perfectly well. 

This case cannot be called one of draining the ven- 
tricle, but merely of an accidental tapping in despair 
at failing to find an abscess. I have cited it as it has 



262 BRAIN SURGERY. 

given rise to a discussion regarding priority in the 
operation. ' 

Robson's second case was one of an infant suffering 
from rapidly increasing hydrocephalus following treat- 
ment of spina bifida by Morton's injection. The skull 
was trephined an inch in front of the fissure of Rolando 
over the second frontal convolution. The dura was opened, 
and the needle of an exploring syringe was inserted into 
the ventricle, which was reached an inch from the cerebral 
surface. By means of Lister's sinus forceps a rubber 
drain was inserted, following the needle as a guide. The 
drainage was so free as to wet the dressings freely, and 
after it the patient seemed much relieved. The drainage 
soon became less free, and on the third day the child died 
in convulsions. The post-mortem showed that the brain 
had shrunk so much that the end of the tube was lying 
between the dura and the brain. 

In the Revue de Chirurgie for January, 1891, Broca 
gives a translation of Keen's article just cited and 
describes two cases of tapping the ventricle, one by 
himself and one by Thiriar of Brussels. 

Broca 's patient was a boy of 4, years of age, who 
had suffered from hydrocephalus and was an imbecile, 
and who had a contracture of the right arm which had 
followed a series of convulsions. The trephining was 
done at the point indicated by Keen, three centimetres 
above and three centimetres behind the left auditory 
meatus. It was noticed that there was no pulsation 
of the dura or of the brain when this was exposed. 
Broca punctured the ventricle with a trocar and canula 

iBrit. Med. Jour., Feb. 2d, etc., 1891. 



TREPHINING FOR HYDROCEPHALUS. 263 

and evacuated sixty grammes of fluid ; he introduced 
a drainage tube through the canula and allowed it to 
drain into the gauze dressings, which were changed 
every day or two. Pulsation returned in the brain 
after the operation. On the sixteenth day a very 
marked improvement was noticed in the child, the 
contracture in the right arm having disappeared. 
The amount of fluid drained away became progres- 
sively less, and on the fiftieth day after the operation 
the wound had entirely healed, and the child was dis- 
charged from the hospital very much better physically 
and mentally. This is the first successful case on 
record. 

The case of Thiriar was one of epilepsy and hydro- 
cephalus with very great exophthalmos and nystag- 
mus. Drainage was established and the ventricle 
washed out. The exophthalmos and nystagmus en- 
tirely disappeared, but several days later the child died 
in convulsions. 

From a review of these cases it is evident that tre- 
phining in hydrocephalus with drainage of the lateral 
ventricle is a possible and fairly safe operation, and 
when the hydrocephalus is not secondary to some in- 
curable affection, the operation may be attended by a 
cure as in Broca's case. It is never possible to deter- 
mine absolutely in the presence of a case of hydro- 
cephalus, whether the distention of the ventricle is 
primary or secondary. In every case, therefore, tre- 
phining should be done, for if the disease is primary it 
may be cured, and if the disease is secondary the 



264 BRAIN SURGERY. 

patient will die and the operation will not necessarily 
hasten the fatal termination. 

A few cases of rupture of the lateral ventricle, of 
abscesses and hemorrhages rupturing into the lateral 
ventricle have been gathered by Keen in his paper 
upon the surgery of the lateral ventricles, but in con- 
ditions of this character it is impossible to make a 
diagnosis sufficiently early to attempt trephining, and 
where trephining has been done in such cases the 
actual condition has not been diagnosticated before 
the operation. It is true that these cases do not all 
die, and Keen has shown that when they have been 
operated upon a few have recovered, but surgery of 
this' character is not to be commended, being venture- 
some and not based upon accurate diagnosis. 

The operation for reaching the ventricle and drain- 
ing it, according to Keen's directions, seems to be a 
simple one. The trephine opening is to be small, one 
inch in diameter, and to be made one and one-fourth 
inch above and one and one-fourth inch behind the 
external auditory meatus, and the direction of the 
puncture of the brain, which is best made with trocar 
and canula, should be toward a point two inches above 
the opposite auditory meatus. Birmingham has shown 
that at this point there is some danger of opening into 
the lateral sinus, and recommends placing the tre- 
phine one-half inch higher. The drainage should be 
kept up by a large bundle of horsehairs, as drainage 
by a tube gives exit to the fluid at too rapid a rate. 
If the drainage is not free. Keen recommends that a 



TREPHINING FOR HYDROCEPHALUS. 



265 



similar operation be done upon the opposite side and 
the ventricle he irrigated with a warm boric acid 
solution. 

The nearness of the descending horns of the lateral 
ventricles to the surface when the ventricles are dis- 
tended with fluid is well shown in Fig. 59. 

This operation is necessarily one of very limited 
application, and when it is considered that its result is 




Fig. 59.— Dilatation of the Lateral Ventricles in Hydrocephalus.— Delafield and 

Prudden. 



to relieve symptoms rather than to remove a patho- 
logical condition, it becomes evident that it is not an 
attractive one either to physician or surgeon. 

Trephining has been done in a number of cases of 
brain tumor with a view of relieving the general in- 
tracranial pressure when the situation of the tumor 
was unknown but the symptoms were exceedingl}'- 
severe. Horsley reported at the Berlin Congress six 
cases of "exposure of cerebral tumor for the relief of 



266 BRAIN SURGERY. 

pressure symptoms with recovery and immediate union 
in all." As he also reported the number of cases of 
cerebral tumor which he had removed (8), it is to be 
supposed that in these cases no tumor was found. 
Mills, Knapp and Bradford, and others have noticed a 
relief of the symptoms in cases of brain tumor which 
had been trephined even though the tumor was not 
removed. Trephining in this case is, of course, merely 
palliative, and yet it may prolong life for several 
months and hence may be employed. It seems to be 
best in such cases to tap the ventricles, since these are 
usually distended with fluid. If this is done. Keen's 
method already described should be the one adopted. 



CHAPTER VIII. 

TREPHINING FOR INSANITY. 

Traumatic Insanity in Relation to Insanity in General. Report of 
Cases Operated Upon. TreiDhiuing in General Paresis. Useless- 
ness of the Operation. 

While it is perfectly evident to any one familiar 
with mental disease that trephining has no place as a 
method of treatment in general, yet there are a few 
cases upon record in which the symptoms of mental 
derangement have developed immediately after a seri- 
ous injury to the head with or without depressed frac- 
ture of the skull. The percentage of cases of insanity 
traceable to traumatism is small. Kiernan ' states 
that 45 cases in 2,200 cases under his care were trau- 
matic. Hays'' found 61 cases in 2,500 under his ob- 
servation; two per cent is therefore a fair estimate. 
In these cases the apparent connection between the 
injury and the development of the mental symptoms 
is so clear as to leave little doubt that the insanity is 
due to the trauma. Under these circumstances tre- 
phining has been thought of and has been successfully 
practised as a method of treatment of the mental 
disease. 

Dr. Carlos F. MacDonald reported such a case as 

^ Jour. Nerv. and Med. Dis., July, 1881. 
^ Amer. Lancet, November, 1891 . 



268 BRAIX SURGERY. 

long ago as 1886/ and collected other cases of the 
same character which had heen recorded prior to that 
time (see page 65). 

Frank and Church have rejDorted ' a case of a young 
woman who developed delirium immediately after a 
severe injury to the head. She became constantly 
worse and finalh' was so unmanageable as to require 
asylum restraint. She suffered from the ordinary 
symptoms of mania, which became chronic and went 
on to complete dementia. She was destructive at 
times, noisy, but for the most jDart sat idly silent and 
stupid. This condition remained from April, 1884, 
until February, 1889, when she was admitted to St. 
Elizabeth's Hospital, Chicago, and carefully examined 
by Prof. Brower. 

The diagnosis was "that the insanity was caused by 
the injury, because of the absence of any other possi- 
ble cause and the immediate connection between the 
two; that the injury need not have jDroduced fracture 
or depression of the skull to have resulted in insanity ; 
that the depression of the skull found might be con- 
genital, but its situation over the right parietal region 
made it possible that it might be the cause of the in- 
sanity ; that this possibility justified exploratory tre- 
phining, and that the danger of the operation was so 
slight that it should not weigh against the possible 
benefit." In accordance with this opinion Dr. Frank 
trephined, removing a large portion of bone about two 

1 Amer. Jour. Med. Sci., July. 1886. 
2Araer. Jour. Med. Sci., July, 1890. 



TREPHINING FOR INSANITY. 269 

inches in each direction from the anterior part of the 
right parietal bone. On dividing the dura a consider- 
able amount of cerebro-spinal fluid gushed out. No 
gross lesion of the dura or brain was found. The 
wound was closed after the buttons of bone had been 
replaced. During the following six months the im- 
provement of the patient was very striking, though 
her mental powers were still very feeble, but in Feb- 
ruary, 1890, she was readmitted to the hospital in 
about the same condition as a year before. The sec- 
ond operation was performed March 24th, 1890, at the 
same location as the first. The buttons of bone were 
found to have united with the skull, but the small 
fragments which had been replaced had been absorbed. 
A large section of bone was removed, the dura and 
brain were again explored without finding anything, 
and the wound was closed, this time without replacing 
the bone. A month later the patient manifested a 
considerable degree of intelligence, memory, and ap- 
preciation of her condition and surroundings; she 
showed natural emotion when told of a slight illness 
of her father, and read a letter without difficulty. 
She presented a great contrast to the condition which 
had been manifest before the operation. This im- 
provement had continued up to the time of the 
report^ one month after the second operation was 
performed. 

While this case cannot be regarded as a marked 
success, the report having been made too soon to war- 
rant any general conclusion, it gives evidence that the 



^70 BRAIN SURGERY. 

<3ourse of a dementia following trauma may be influ- 
enced by trephining. 

Dr. Keen reports the following case : A male, aged 
41, after a fall from horse developed delusional insan- 
ity. He heard imaginary Toices and these led to 
delusion. These delusions led in July, 1890, to an 
attempt at suicide ; the imaginary voice told him that 
he was about to be killed by some one pursuing him, 
and another voice said, ''Don't let them kill you, but 
do it yourself." Accordingly he ^Drocured a revolver 
and shot himself, but recovered from the wound. For 
several mouths later his delusions continued and hal- 
lucinations of sight were also present. In October, 
1890, he complained of constant headache, especially 
in the right parietal region which was the seat of the 
injury, and he heard voices constantly. He had no 
delusions of persecution and was quiet and docile; 
there were no physical symptoms of brain disease. 

Dr. Keen trephined October 17th, 1890, over the 
depressed bone. The scalp was adherent to the skull, 
the bone was rather thin, the dura was adherent to 
the bone, there were no adhesions to the pia, and the 
brain appeared normal. He made an uneventful re- 
covery and was up two weeks after the operation. 
The pain in his head was very much less, and he did 
not hear voices nor did he have any delusions after 
the operation. Six weeks later he was considered by 
his wife and employer much more rational than he 
had been, and was able to do light work. The im- 
j)rovement was not, however, permanent, and four 



TREPHINING FOR INSANITY. 271 

months later he was reported in about the same con- 
dition as before the operation. 

The number of cases thus far trephined for trau- 
matic insanity is too small and the operation has been 
performed at a period too far removed from the 
trauma to warrant any definite conclusion as to the 
propriety of this form of treatment. But it seems 
probable that in appropriate cases, where the derange- 
ment begins soon after the trauma and where an 
injury of the skull is evident, an early trephining may 
cut short the mental disease and prevent its going on 
to a condition of chronic dementia. 

The mental symptoms which are likely to develop 
after injury of the head are those of mania or of de- 
mentia, other forms being rarely recorded. There is 
no reason to conclude that insanity not traumatic in 
origin is amenable to surgical treatment, and Burck- 
hart's proposal made at the Berlin International Medi- 
cal Congress, to trephine in chronic cases and make in- 
cisions at random into the brain, deserved the severe 
censure which it met with. 

Trephining has been proposed as a form of treci- 
ment of general paresis, and it has been performed in 
several cases under the direction of Batty Tuke and 
Claye Shaw in England, and by Wagner in this coun- 
try.^ In some of these cases it has failed to produce 

1 Claye Shaw: Brit. Med. Jour., Nov. 16th, 1889. Revington : 
Brit. Med. Jour. , Nov. 23d, 1889. T. Batty Tuke : Brit. Med. Jour. , 
Jan. 4th, 1890. R. Percy Smith : Brit. Med. Jour. , Jan. 4th, 1890. 
Claye Shaw: Brit. Med. Jour., Sept. 12th, 1891. St. Bartholomew 
Hosp. Rep., 1892. Wagner: Amer. Jour. Insanity, July, 1890. 



272 BRAIN SUROERY. 

any effect ; in other cases there has been a shght tem- 
porary improvement, such as may occur spontaneously 
in any case of general paresis at any time. No per- 
manent results have been obtained, and the consensus 
of opinion at the British Medical Association at its 
meeting in 1891, when the subject was fully discussed, 
seems to have been against this method of treatment 
in general paresis. The plea was made for the opera- 
tion that it would relieve the condition of intracranial 
pressure and give exit to fluid which is usually found 
upon the convexity of the brain in states of dementia. 
The reply made to this was that the state of fluid 
exudation was secondary to the lesion in progress in 
the brain, and that the trephining in no way affected 
.the actual disease, which was the primary cause of the 
symptoms. It seems to me that in general paresis, a 
disease which has an. organic lesion, a diffuse chronic 
meningo-encephalitis, it is impossible for the operation 
of trephining to do any good whatever. Even should 
it act as a palliative treatment, it is not to be encour- 
aged, for it is very questionable whether there is any 
gain in prolonging life in such a hopeless and progres- 
sive form of mental derangement. 



CHAPTER IX. 

TREPHINING FOR HEADACHE, AND OTHER 
CONDITIONS. 

HoRSLEY and Weir have performed the operation of 
trephining in two cases of localized headache of trau- 
matic origin with success. The patients had both de- 
veloped the headache subsequently to a blow without 
any fracture of the skull, and every form of treatment 
had been employed in vain before the aid of the sur- 
geon was sought. In both cases the pain was a strictly 
local one, not of the nature of ordinary headache. In 
Horsley's case there was found an enlarged Pacchi- 
onian body eroding the dura and skull. In Weir's 
case the mere removal of a button of bone relieved the 
pain. Such cases are certainly rare, and it is evident 
that no special consideration need be given to trephin- 
ing as a form of treatment for headache. 

It has been suggested that in cases of meningitis it 
might be possible to make two or more openings in 
the skull and wash out the pus from the meninges ; 
this idea having been suggested by the successful sur- 
gical treatment of peritonitis. Any one, however, who 
is familiar with the surgery of the brain will realize 
that trephining does not give access to any great ex- 
tent of the meningeal surface, and any one who is 
18 



274 BRAIN SURGERY. 

familiar with pathology will realize the impossibility 
of removing pus from the interstices of the cerebral 
membranes. 

Trephining for the treatment of thrombosis of the 
lateral sinus occurring in connection with middle ear 
disease has been proposed. Those who are interested 
may consult the article by Ballance in the Lancet for 
May mh and 24th, 1890. 

Trephining for the removal of bullets and foreign 
bodies from the brain is a purely surgical subject and 
is treated in the text-books upon surgery. 



CHAPTER X. 

THE OPERATION OF TREPHINING. 

This book would be incomplete did it not contain a 
chapter upon the technique of opening the skull. 

I have seen this operation performed so many times 
in such different ways, by different surgeons, that I 
am quite familiar with it. But in the preparation of 
this chapter I have made use of articles by Park, by 
Horsley, by Von Bergmann, by Weir, and by Keen. ' I 
have to thank Dr. McBurney for reading this chapter 
and for many valuable suggestions in its preparation. 

It is an absolute requisite of success in cerebral 
operations that every detail of aseptic surgery should 
be carried out to perfection . It is useless to make 
elaborate preparations, to sterilize instruments, and to 
apply antiseptic solutions to the hands, if in the midst 
of the operation the surgeon stops for a moment to 

^ Horsley : Brit. Medical Journal, October lOtli, 1886, and April 
23d, 1887. Transactions Berlin Internat. Med. Congress, 1890. 

Park: "Surgery of the Brain," N. Y. MedicalJournal, November, 
1888. 

Von Bergmann : " Die Chirurgische Behandlung der Hirnkrank- 
heiten," 1891. 

Keen : " Surgery of the Brain, " " Reference Handbook of the Medi- 
cal Sciences, " vol. viii., 1888, and "American System of Surgery," 
1892. 

Weir : American Journal of the Medical Sciences, July, 1888. 

Macewen: Brit. Med. Jour., Aug. 11th, 1888. 



276 BRAIN SURGERY. 

adjust his septic eyeglass, or to blow his nose on a 
septic handkerchief without subsequently washing his 
hands again, or receives an instrument from the hands 
of assistant or nurse which have not been specially 
prepared for the operation. By covering his hand 
with a wet aseptic towel, the surgeon can safely 
handle anything which he desires. When aseptic 
measures are carried out in perfect detail, the rapidity 
of healing after these operations upon the brain is 
something marvellous. Thus, in an extensive opera- 
tion, by Dr. McBurney where the incision in the scalp 
measured seven inches, and the division of the skull 
along a line measured six inches, and the entire bony 
flap was broken away, exposing an area of the dura 
several square inches in extent, the wound was entirely 
healed within a week of the time of operation. And 
in the majority of the cases which have been here 
given in detail, a favorable and immediate healing 
was secured. It is to be understood, therefore, that 
in these operations the patient is to be properly pre- 
pared and the scalp made aseptic; that the hands of 
the operator and his assistants shall all be prepared ; 
that the field of operation shall be surrounded over a 
wide area with sterilized towels either wet or dry 
(preferably wet), and frequently renewed; that every 
instrument, sponge, towel, etc., shall have been ren- 
dered aseptic, either by subjection to boiling heat in a 
steam sterilizer or by being soaked in a strong anti- 
septic solution, such as carbolic acid 1 : 50 or bichlor- 
ide 1:1000. 



THE OPERATION OF TREPHINING. 277 

The Preparation of the Patient. — The patient's 
head is to be entirely shaven twenty-four hours be- 
fore the operation and carefully washed with soft soap, 
being scrubbed with a nail-brush, then washed again 
with warm water, and then again with sulphuric ether, 
each successive drying being done with an aseptic 
towel sterilized by heat. The head is then to be en- 
veloped in a corrosive-sublimate gauze dressing which 
is applied moist, having been soaked in a solution of 
bichloride, 1 : 2000, and bandaged with aseptic ban- 
dages. Stronger solutions may cause eczema of the 
scalp. This bandage is to be left on until the opera- 
tion is begun. The preparatory treatment by a pur- 
gative and the selection of a time for operation several 
hours after a meal are not to be neglected. It is best 
to suspend the administration of bromides for a week 
before any operation. 

The choice of an ancBsthetic may be left open to the 
surgeon, but I can verify the statement that the hem- 
orrhage from the cerebral vessels is much less intense 
when chloroform rather than ether is used. Horsley 
has suggested the hypodermic injection of morphine, 
one-sixth of a grain, prior to the operation. Keen has 
recommended ergot, two to four drachms. The object 
of both is to produce a contracting influence upon the 
cerebral vessels. I have seen morphine act efficiently 
in this respect. 

The marking off upon the^ scalp of the fissures of 
Eolando and Sylvius requires some time and should 
in my opinion be done before the anaesthetic is admin- 



278 BRAIN SURGERY. 

istered . These lines, after being carefully laid down, 
should be marked upon the scalp with iodine. A 
light touch at a series of points with the Paquelin 
cautery, after the anaesthetic is administered, fixes the 
lines. It is also well to puncture the scalp at three 
points with a sharp instrument, an awl or gouge, and 
thus mark the bone along the line which it is most 
important to regard; so that when the scalp is re- 
tracted the position of the guiding line, whether it be 
the fissure of Eolando or the fissure of Sylvius, shall be 
clearly evident upon the bone. This I think is impor- 
tant, as it is difficult to replace the scalp in the exact 
position after it has been dissected up, and the mark- 
ings of the scalj) may be somewhat obliterated by the 
solutions used in cleaning it after the lines have been 
laid down. It is also well to make a mark on the 
skull through the scalp with a sharp instrument at 
the exact point at which the centre of the trephine is 
to be placed before the scalp is divided. After the 
ansesthetic is administered the scalp is to be again 
carefully washed with (1) soft soap and hot water 
with the nail-brush, (2) with sulphuric ether, (3) with 
absolute alcohol, (I) with a solution of corrosive sub- 
limate, 1 : 1000. 

The application of a rubber band around the scalp 
just above the eyebrows for the purpose of compress- 
ing the vessels and preventing hemorrhage on the 
principle of the Esmarch bandage, which I suggested 
to Weir in 1887, is a failure. It cannot be applied 
with sufficiently even pressure to compress the arte- 



THE OPERATION OF TREPHINING. 279 

lies ; it merely exerts pressure upon the veins and in- 
creases venous hemorrhage; it should be abandoned. 
Weir's device of passing four long needles at right 
angles to one another through the scalp, thus making- 
pressure on all the vessels leading into the flap, is far 
better. It is of great service both during and after 
the oiDeration to have the patient's head on a level 
above the body, and a semi-sitting posture is the one 
in which hemorrhage is the least. It is not to be for- 
gotten that when chloroform is used as an ansesthetic 
this position is attended by danger. 

The incision in the scalp should be of horseshoe 
shape, base downward, or so directed as to secure the 
best nutrition and sufficiently large to allow of the 
easy enlargement of the bone opening in case it should 
be necessary to enlarge this to twice the size antici- 
pated. The chief hemorrhage during the operation 
comes from this incision in the scalp, yet nothing is to 
be gained by making the incision little by little, inas- 
much as the edges of the incision must be easily 
accessible in order to reach the bleeding vessels. The 
better way appears to be to make the incision in three- 
fourths of its expected length with the first sweep of 
the knife, to have the scalp compressed by sponges or 
sterilized gauze in the hands of assistants as fast as 
the cut is made, and then to catch the vessels one by 
one with forceps as the sponges are lifted. Several 
varieties of forceps are in use for this purpose ; either 
the blunt dog-tooth forceps of McBurney or the broad 
T-shaped end forceps of Gerster may be employed; 



280 BRAIN SURGERY. 

the latter grasp a portion of the scalp nearly an inch 
in breadth and hold it firmly for a time : a series of 
these may be applied along the incision, and then one 
by one they may be removed and the vessels caught 
with a single- tooth forceps and tied. When the bleed- 
ing is arrested from the original incision it may be 
extended at both ends to its intended size, the vessels 
near being successively caught and ligated. 

In dissecting up the scalp the periosteum should he 
left upon the bone and not dissected up with it. 

Surgeons differ as to the best method of making an 
opening through the skull, but all agree that whatever 
opening is made should be at least one and one-half 
inch in diameter, and many prefer the opening at 
least two inches in diameter. Such openings may be 
made by trephining at one spot with a trephine one 
and one-fourth inch in diameter and enlarging the 
opening with a rongeur, or by making two trephine 
openings an inch in diameter and cutting away with 
a rongeur the bridge of bone between, or by chiselling 
with gouge and mallet through the skull, or lastly by 
the use of the rotary saw run by an electric motor. 

If the trephine is used care should be taken not to 
wound the dura when nearly through the skull. In 
using the rongeur the instrument of Horsley with its 
jaw at an angle with the shank is far more conven- 
ient than a straight instrument. If the gouge is used 
great care must be exerted to prevent its slipping and 
cutting the dura. The concussion produced by ham- 
mering is an objection to the use of the gouge or chisel 



THE OPERATION OF TREPHINING. 281 

urged by some American surgeons. But this objec- 
tion is not sustained by Dr. McBurney's experience. 
German surgeons prefer this method. If the gouge 
is used the opening in the skull may be made of i2 
shape and the plate of bone be then gently pried 
up, the attached part being broken but not separated. 
The electric motor with a rotary saw is a satisfactory 
instrument for cutting the bone. In order to use it 
safely a trephine opening must first be made, the dura 
must be carefully separated from the bone by a thin 
flat metal instrument, and the instrument must be 
held in place to protect the dura, and be pushed for- 
ward in advance of the saw as this is used. The 
difficulty of directing this flat instrument through the 
trephine hole, and the danger of sawing into the dura 
and brain if it is not properly placed, are great. It 
requires much practice and skill to handle the electric 
saw safely, and to an observer the danger of sawing 
through into the dura and brain seems to be great 
unless the metal plate between skull and dura is very 
flrmly held and accurately adjusted. Yet the labor 
of trephining is so great and so wearisome that any 
mechanical electric motor would appear to be prefera- 
ble to the hand, and as Horsley's apparatus can be so 
adjusted as to revolve the trephine, it seems as if the 
first two-thirds of the trephining can be safely done 
with it, the last third being done by hand so that 
touch shall guide the degree of pressure made upon 
the trephine. It is of course in a hospital only that 
the electric motor can be used. 



282 BRAIN SURGERY. 

The question of replacing the piece of hone that has 
been removed is an open one. If a single button of 
bone is removed, or if two buttons and the bridge be- 
tween them are taken out, it is possible to replace them 
and to secure bony union. It is also possible to re- 
place the large plate removed by the Horsley saw. 
But of late when larger openings are made by gnaw- 
ing away the bone about the original trephine opening 
the bone is rarely replaced. If it is to be replaced it 
should be kept at a temperature of 99° by being 
wrapped in warm damp gauze wet with a corrosive 
sublimate solution, 1 : 2000, or in a sterilized salt 
solution, and kept in a warming box or in a jar im- 
mersed in w^arm water. It is also possible to preserve 
the small pieces of bone and to cut up the larger piece 
and replace them all by strewing them over the dura. 
It should be remembered, however, that such pieces 
of bone, no matter how carefully taken care of in the 
interim, may necrose after replacement. To avoid 
this accident McBurney never replaces a piece which 
has been entirely separated, and for the same reason 
he prefers lifting a plate of bone which is never en- 
tirely detached, and so never entirely cut off from a 
source of nutrition. 

There is sometimes considerable liemorrliage from 
the diplo'e, and occasionally a vein or a large canal in 
the diploe will bleed profusely. Pressure with sponge 
at the bleeding spot usually stops this. If it persists 
Horsley's wax may be used, which consists of wax 
seven parts, oil two parts, carbolic acid one part. 



THJE OPERATION OF TREPHINING. 28)3^^ 

This may not be sufficient to arrest hemorrhage from 
a large vein, and then a small plug of decalcified bone 
or of aseptic sponge may be forced into the opening. 
The two tables may be forcibly crushed together by a 
heavy forceps and thus the bleeding from the diploe 
stopped. 

The division of the dura is made by the point of a 
curved bistoury, or an ordinary scalpel. A fine tena- 
culum then seizes the dura and draws it up from the 
brain surface, and into the small incision a curved 
blunt scissors blade can be inserted and the dura 
freely divided. The dura should be divided about one- 
fourth inch from the edge of the bony opening and 
the incision should be horse-shoe in shape. The dura 
can then be refiected downward leaving the brain ex- 
posed. It should be lifted carefully away from the 
brain, for very frequently close adhesions exist which 
cannot be roughly torn without incurring great risk 
of opening one or more large veins of the pia mater. 
If arteries are found passing over the dura they should 
be ligatured before the dura is divided. This is best 
done by Keen's small, curved needle attached to a 
handle, similar to an aneurism needle but very minute. 
A curved Hagedorn needle may be used. This can be 
passed around the vessel through the dura and a liga- 
ture threaded into it and drawn backward, thus sur- 
rounding the vessel. The same needle can be used in 
sewing up the dura at the end of the operation, the 
ordinary curved surgical needles being too large. 
Hemorrhage from little vessels of the dura is best ar- 



284 BRAIN SURGERY. 

rested by a light touch with the cautery if pressure 
is insufficient. 

The brain is now exposed — covered by pi a mater, 
whose numerous vessels are easily torn at the least 
rough manipulation. If it is necessary to dissect off 
portions of the pia — in removing scar tissues or tumors 
— or if it is necessary to incise the brain for the exci- 
sion of cysts or tumors, hemorrhage may give some 
trouble. It can usually be arrested by continued 
pressure with sponge or with aseptic gauze. During 
the time that this pressure is being maintained, liga- 
tures may be applied to bleeding vessels of the scalp, 
or the wound may be cleaned and new towels applied ; 
thus no time is wasted. If pressure alone is not 
enough to stop hemorrhage from the pia a clamp or 
forceps may be applied for a time, and if it continues 
when this is removed the vessel may be tied with very 
fine catgut. As a last resort the Paquelin cautery 
may be employed, but it is less useful in the vessels of 
the pia than in those of the dura. Pressure alone is 
usually sufficient to arrest hemorrhage from the brain 
substance itself, though a cautery may be needed. It 
is impossible to tie the little brain arteries and veins. 
Solutions of antipyrine 1 : 40, or of cocaine 1 : 100, have 
been used as styptics by Keen and Park. 

Exploration of the Brain may be made by palpation, 
and this is exceedingly satisfactory, for the degree of 
resistance to pressure may be contrasted at various 
points and the fluctuation of a deep cyst or the hard- 
ness of a solid tumor can be easily noticed. 



THE OPERATION OF TREPHINING. 285 

If necessary a probe may be thrust into the brain or 
a hypodermic needle may be introduced quite freely 
and without danger, as Spitzka has shown. Incisions 
into the brain are not dangerous, but if they are made 
the knife should be passed down through the summit 
of a convolution, as then hemorrhage is less free than 
when the side of the convolution or the brain at the 
bottom of a sulcus is incised. When it is remembered 
that large portions of brain tissue have been destroyed 
by accidents {e.g., in the crow-bar case and in the 
linch-pin case) without fatal results, less fear will be 
felt on wounding the brain. Yet it is to be also re- 
membered that certain parts of the cortex have im- 
portant functions — such as the speech areas or the mo- 
tor areas — and all needless incision or excision should 
be avoided. 

If there is much oedema of the pia, a few small in- 
cisions in it followed by pressure will evacuate the 
fluid. 

If a clot is found it may be wiped away by fine 
sponges or, if organized, picked out with fine forceps, 
care being taken not to tear the pial veins. 

If a tumor lies upon the surface, and is surrounded 
by a distinct capsule, it can be enucleated with the 
blunt point of curved scissors or with the finger with- 
out cutting. If it infiltrates the brain tissue and so 
has no distinct capsule, it should be cut out with the 
knife. The sharp spoon does not do good work in the 
brain. If the tumor lies below the surface, the brain 
tissue lying over it must first be incised and then enu- 



^86 BRAIN SURGERY. 

cleation or dissection of the tumor from its bed may 
be done, the overl^'ing substance being held away with 
flat retractors. If a cyst exists, it may be when 
superficial completely excised, or its superficial sur- 
face wall may be cut away and the remainder packed 
and healed by granulation. If the cyst lies deeper, it 
may be freely incised and packed, or a small incision 
for drainage may be made, and continuous drainage 
kept up by introducing a folded strip of rubber tissue 
through the incision. 

The same device may be resorted to in draining an 
abscess. 

After the removal of large tumors or cysts, or 
after the excision of large scars from the brain, a de- 
pression of the surface or a deej) cavity may remain 
which if left to itself inevitably fills with blood. This 
may be avoided by packing such a cavity lightly with 
iodoform gauze, which at subsequent dressings maybe 
removed little by little. It is well to use a single strijD 
of gauze, otherwise the number of pieces used may not 
be accurately counted or remembered and one piece 
may never be removed. A tampon of folded aseptic 
gauze may be used in place of the iodoform packing. 

If the operator has confidence in his methods, he 
might in some suitalle cases, where bleeding was not 
active, practise the ideal method by allowing the cav- 
ity to fill with blood, and so get healing with organi- 
zation of blood clot. One or more openings must be 
left in the suture line to allow of the escape of super- 
fluous blood. 



THE OPERATION OF TREPHINING. 287 

A very marked bulging of the brain tissue through 
the opening in the dura mater sometimes occurs at 
the time of the operation, or subsequently to it, as a 
hernia cerebri. It has been found that the smaller 
the opening in the dura the more likely this is to 
occur. If the bulging tissue be held back by a fiat 
spatula while the stitches are put in the dura and a 
continuous suture be used, and then the edges of the 
dura be rapidly drawn together as the spatula is re- 
moved, the bulging will be slowly reduced. If this is 
impossible the bulging brain may be sliced off or 
wiped away with a sponge. Hernia cerebri develop- 
ing after the operation is rare when asepsis is perfect. 

In case a sinus or a large vein is opened and hem- 
orrhage becomes alarming the wound may be pa.cked 
with iodoform gauze with safety, or the wound in the 
sinus having been closed with a pressure forceps, the 
forceps may be left in place for a day or two supported 
by the dressings. Sewing up a bleeding sinus is diffi- 
cult, but has been done successfully. 

The closing of the ivoiind should be preceded by a 
thorough irrigation with simple sterilized salt solu- 
tion, one per cent, or with corrosive sublimate, 
1 : 5000. A small drain of a folded bit of rubber 
tissue should be left in the most dependent part of the 
wound. The dura should be stitched with catgut ex- 
cept where the drain passes through it. The scalp is 
then to be stitched with silk. The head is to be 
washed with antiseptic solution. The wound is then 
to be covered with rubber tissue. It is to be covered 



.288 BRAIN SURGERY. 

with aseptic gauze and this with many layers of cot- 
ton, and the whole held in place by a large bandage 
covering the entire head and held under the jaw. 

In some cases there may be no necessity for a drain, 
in which case the entire dressing need not be changed 
for a week, when everything may be found to have 
united by first intention. 

In other cases the drain may be removed on the 
third day and a second dressing applied — removal of 
which may be found to show a healed wound. 

Damming up of blood giving rise to pressure symp- 
toms, or the extreme oozing of cerebro-spinal fluid, or 
the development of a temperature with evidence of 
infection, necessitate an immediate inspection of the 
wound by the removal of dressings, and proper care 
upon general surgical principles. 



THE END. 



INDEX. 



Abscess of the brain, 179 
capsule in, 182 
cases of, 183 
cases operated upon, 183, 184, 

194, 195 
causes of, 180 
diagnosis of, 188, 189 
differentiation from menin- 
gitis, 190 
from sinus thrombosis, 
190 
following ear disease, 188 
fevers, 180 

injury of the skull, 183 
pathology of, 181 
position for trephining in, 

193 
symptoms of, 189 
trephining for, 182 
varieties of, 180 
Agnew, 181, 227, 253 
Agraphia, 6 
Alexia, 6 
Amidon, 253 

Anaesthetic in trephining, 277 
Anderson, 252 
Anger, 137 

Aphasia, 6, 23, 42, 45, 48, 145, 
158, 160, 162, 174, 183, 188, 214, 
219, 228, 261 
Apoplexy, trephining in, 176 
Arm, motor area of, 3 

spasm in, 20 
AsJiby, 117, 133 

Association tracts in the brain, 
10 

19 



Atrophy of the brain, 125, 129 
Auditory area of the brain, 6 
speech, 7 

Ball, 158 
Ballet, 251 
Barker, 197 
Barr, 188 
Barton, 251 
Bartlett, 137, 224, 251 
Basal ganglia, 11 
Base of the brain, 11 

tumors of, 210 
Beach, 252 
Bennett, 251 
Bennie, 137 

Von Bergma^in, 195, 20j, 251, 275 
Bernhardt, 215 
Birdsall, 221, 251 
Birmingham, 194, 264 
Birth palsy, 116 
Blindness, 121, 229, 246, 248 
Bone, lesions after injury, 69 

replacing after trephining, 
282 
Booth, 205, 251 
Boyd, 166 

Bradford, 137, 223, 252, 253 
Brain, bulging of, after trephin- 
ing, 287 

changes in, in epilepsy, 73 

exploration of the, 284 

wounds of the, 76 
Bramivell, 207 
Braman, 252 
Bremer, 225, 252 



290 



INDEX. 



Briddon, 41 
Broca, 262 
Brower, 268 
Bryant, 62, 184 
Bullard, 137, 253 



Carcinoma of the brain, 202, 204, 

206 
Carson, 225, 252 
Castro, 252 
Centrum ovale, 10 
Cerebellum, 11 

abscess of the, 188 

tumors of the, 238 

cases operated on, 241-253 

staggering in, 239 

symptoms of, 238 
Cerebral abscess, see Abscess, 179 

diseases, 1 

functions, 3 

hemorrhage, see Hemor- 
rhage, 131 

tumor, see Tumor, 200 
Championniere, 173, 251 
Charcot, 21 
Chisholm, 253 
Choked disc, 189, 190, 217, 238, 

257 
Chubbe, 252 

Church, 55, 223, 252, 268 
Clarke, 252, 253 
Claye Shaw, 271 
Clinical types of microcephalus, 

114 
Coen, 76 
Combe, 251 

Compression of the brain, 167 
Congenital defects of the brain, 

128 
Consciousness after hemorrhage, 

169 
Corpora quadrigemina, 11 

striata, 11 
Cortical areas, 3 



Cranial nerves, symptoms of in- 
jury to, 240 

Cranio- cerebral topography, 15 

Craniotomy for microcephalus, 
114, 136 
table of cases of, 137 

Crura cerebri, 11 

Cunningham, 15 

Curtis, B. F., 205, 251 

Cysts in the brain, 74, 130, 203, 
207, 284 

Czerny, 218 

Dana, 215, 252 

Danger of trephining in epilepsy, 

27 
Deaf -mutism, 120 
Deafness in brain disease, 7, 240 
Deaver, 55 
Dementia, 268, 271 
Derby, 229 
Detmold, 179 
Diller, 57 
Direction of staggering as a local 

symptom, 239 
Dobson, 253 
Donaldson, 120 
Doyen, 252 
Drainage of lateral ventricles, 

256 
Dunin, 252 
Dupuytren, 179 
Durante, 251 

Dura, changes in, in epilepsy, 70 
treatment of, after trephin- 
ing, 283 

Elcan, 183 

Epilepsy, trephining for, 19 

aphasic attacks, 23 

cases open to trephining, 24 

cases trephined, 29-69 

causes of, 25 

following injury, 261 

idiopathic, 19, 117 



INDEX. 



291 



Epilepsy in microcephalic chil- 
dren, 124 

in tumor of the brain, 217 

Jacksonian, 20 

lesions of, 68, 75, 78-112 

pathology of, 68-112 

psychical attacks, 23, 65 

reflex, 68 

results of trephining for, 112 

sensory attacks, 22 

traumatic, 25 

varieties of. 19 

with insanity, 65, 267 
Erh, 217, 252 
Eskridge, 252 
Excision of cortex, 27 
Extra -dural hemorrhage, 168 
Eyes, motor area of, 3 

Face, motor area of, 3 

Facts of localization, 3 

Feiiger, 183 

Ferraro, 126 

Ferrier, 21, 232 

Fischer, 251 

Fisher, E. D., 62, 63, 64, 122, 

129, 138 
Fissures of the brain, 3, 15 
Fitzgerald, 251, 253 
Fracture of the skull, 69 
Frank, 55, 133, 137, 252, 268 
Eraser, 253 
Freimd, 123 
Frontal lobe, functions of, 8 

lesions of, 219, 231 
Functions of cerebellum, 11 

of cortex, 4 

Gerster, 59, 60, 61, 62, 137, 279 

Glioma, 202, 207, 245, 247 

Glio-sarcoma, 207 

Godlee, 251 

Gowers, 116, 133 

Gray, 253 

Griffith. 232 



Gumma, 203, 206 

Hahn, 185 
Hallucinations, 22 
Hammond, 137, 138, 253 
Hartley, 48, 138, 144 
Hays, 267 

Headache, trephining for, 273 
Head, injury of, as cause of ab- 
scess 183 
of epilepsy, 26, 121 
of hemorrhage, 158 
of insanity, 267 
motor area of, 3 
Heath, 253 
Hemianopsia, 7, 121, 123, 167, 

214, 218 
Hemiplegia in children, 115 
Hemorrhage, 131 

cases of, 158, 161, 166 
extra-dural vs. intra- dural, 

168 
from the brain after trephin- 
ing, 284 
from the diploe, 282 
from the pia, 283 
intra-cerebral, 176 
non- traumatic, 172 
traumatic, 123, 158, 167 
trephining for, 131, 157 
Henschen, 7, 123 
Heurtaux, 137 
Hirschfelder, 220, 251 
Hitzig, 179, 252 
Hodenpyl, 236 

Horsley, 5, 76, 136, 138, 203, 206, 
237, 251, 252, 265, 273, 275, 280, 
281, 282 
Hydrocephalus, 132, 256 
cases of, 259 
diagnosis of, 257 
draining ventricles in, 258 
trephining for, 256 

Imbecility, 114 



292 



INDEX. 



Incision in scalp in trephining, 

279 ^ i 

Infantile hemiplegia. 115 I 

Insanity. 267 

cases open to operation. 267 

cases ti-ephined. 268 

dementia. 268 

paresis. 271 

traumatic, 267 

trephining for. 267 
Internal capsule, 11 
Inti'a-dural hemorrhage, 168 

Jackson, Hughlings. 19. 20 
Jacksonian epilepsy. 20 
Jacobson, 168 
Janeway. 183 
Jeannel. 252 

Kelly, 64. 65 

Keen, 55, 56. 57. 136. 137. 2-22. 
251. 258. 260. 270. 275. 283. 284 
Keetley, 253 
Kerr, 253 
Kieman, 267 

Knapp, 58, 59, 215, 223. 252, 253 
Koehler. 252 
Koerner, 188 
Kuchenmeister, 203 
Kundrat, 133 

Lanipiasi, 252, 253 

Lannelongue, 136 

Leg, motor area of, 3 

Llobet, 252 

Lloyd, 55. 215 

Limont, 251 

Localization of brainf unctions, 3 



JlacDonald. C. F. 
JLaceicen, 157, 251 
Jdaiidsley. 253 
JIaunoury, 137 
Maunsell, 252 



i5. 267 



:\laAj. 252 

Mal-development of brain. 124 
Marking the scalp before trephin- 
ing. 177 
McBurney. 30. 32, 33. 35. 39. 44, 
45, 50, 52, 53. 68. 138, 141, 147, 
163, 233. 243. 246. 249, 251, 252, 
253, 275, 279, 282 
Mcaintock. 137 
Mcyutt. 133 
Medulla, 11 

Meningeal hemorrhage. 117 
Meningitis, 72, 273 
Meningo-encephalitis. 117. 129. 

271 
Mental defects in frontal lesion, 
219, 231 

in microcephalus, 118 

faculties, 9 
Jlercauton, 252 
Michaucc, 173 
Microcephalus. 114 

cases of, trephined. 137 

clinical types of. 114 

conclusions regarding tre- 
phining for, 155 

epilepsy with, 115, 117 

imbecility from, 118 

paralysis from, 115 

pathology of. 124 

results of ti^ephining for. 139 

sensory defects with, 120 
Microscopic lesions in epilepsy, 

79. 83, 102 
Middle meningeal artery. 169 
MillS: 215 
Moeli, 123 
Jlorrison, 57. 138 
Morse, 253 
Motor aphasia, see Aphasia 

area of brain, 3 

ti-act in brain. 9 

Neuritis optica in abscess of 
brain, 189, 190 



INDEX. 



293 



Neuritis in hydrocephalus, 257 
in sinus tlirombosis, 190 
in tumor of brain, 204, 206, 
212, 217, 238 
Neuroglia, changes in, in epi- 
lepsy, 99-106 
Nothnagel, 21 
Nugent, 253 

OcTJLO-MOTOR paraljsis, 209 

Opening the skull, methods of, 
280 

Oppenheim, 137, 252 

Operation of trephining, 275 

Optic neuritis, see Neuritis op- 
tica 

Optic thalamus, 11, 214 

Organic epilepsy, 20 

Osier, 116, 128, 133 

Page, 251 

Paralysis from brain disease, 3 

of cranial nerves, 209 
Paresis, trephining for, 271 
Park, 66, 138, 149, 153, 275, 284 
Parker, 251 

Pathology of abscess of the brain, 
181 

brain diseases, 79 

cerebral atrophy, 126 

cerebral sclerosis, 124 

epilepsy, 25, 68 

hydrocephalus, 256 

insanity, 272 

microcephalus, 256 

porencephalus, 128 

tumors of the brain, 208 

wounds in the brain, 76 
Pean, 251, 252 
Periosteum, changes in, 69 

treatment of, 280 
Peterson, 122 
Pia mater, changes in, 70, 71 

treatment of, 280 
Pitcher, 252 
Poirier, 252 



Pons Varolii, 11 
tumors of, 209 

Poore, 46, 185 

Porencephalus, 125 

Post, 58, 59 

Potempski, 252, 253 

Poulson, 188, 189 

Preparation of head for trephin- 
ing, 277 

Preugmeber , 138 

Projection tracts in the brain, 9 

Psychical epilepsy, 23 

Punctured wounds of the brain, 
158, 285 

Pupils in cerebral compression, 
170 

Putnam, 253 

Rannie, 251 
Reid, 16 

Relation of fissures and sutures, 
13 
of skull and brain, 12 
Replacing bone after trephining, 

282 
Results of trephining in abscess 
of brain, 181 
in epilepsy, 28, 54, 67, 

112 
in hemorrhage, 167, 171 
in hydrocephalus, 263 
in insanity, 271 
in microcephalus, 137, 

155 
in tumor of brain, 216 
Retinal carcinoma, 214 
Reynier, 252 
Rheinhardt, 120 
Robson, Mayo, 261, 262 
Roland, 21 

Rolando, fissure of, 16 
Ross, 253 
Rumpff, 203 

Sachs, 59, 60, 61, 62, 116, 133, 137 



294 



INDEX. 



Sands, 253 

Sarcoma of brain, 202, 207 

Scalp, incision in, 279 

wounds of, 68 
Scars in brain, 76 

in scalp, 68 
Sciamanna, 253 
Shattenberg, 125 
Schneider, 160 
Schoenthal, 232 
Schultze, 128 
Sclerosis of brain, 125 
Seguin, 221, 251, 253 
Sensory aphasia, see Aphasia 

areas of cortex, 3 

aura in epilepsy, 22 

defects in imbeciles, 120 

epileptic attacks, 22 
Shaw, 58 
Sheldon, 232 
Sight area of cortex, 6 
Sinus, thrombosis of lateral, 190 

treatment of, in trephining, 
287 
Skull, fractures of, 69 

relation to brain, 12 
Smell area of cortex, 8 
Sound area of cortex, 7 
Spasms localized, 22 

order of extension of, 21 
Specific treatment in tumor, 254 
Speech areas of cortex, 3 
Spitzka, 285 
Springthorpe, 253 
Staggering, as a symptom, 239 
Starr, 21, 138, 231, 251, 252 
Statistics of trephining, see Ee- 

sults 
Stewart, 253 
Stieglitz, 252 
Stimson, 184, 194 
Stoker, 253 
Strumpell, 133 
Suckling, 252 
Sylvius, fissure of, 17 



Table of cases of craniotomy, 
137 
of tumors of the brain, 202 
open to operation, 213 
operated upon success- 
fully, 251 
operated upon unsuccess - 
fully, 252 
Taste, area of, in cortex, 8 
Thiriar, 263 
Thomas, 224, 251 
Thompson, 232 

Thrombosis of lateral sinus, 190 
trephining for, 190, 274 
of veins of pia, 133 
Topography, cranio-cerebral, 15 
Tracts within the brain, 10 
Trauma as a cause of abscess, 
180 
epilepsy, 25 
hemorrhage, 160 
insanity, 267 
Trephining for abscess of the 
brain, 180 
clots on the brain, 170 
epilepsy, 13, 19 
headache, 273 
hemorrhage, 157 
hydrocephalus, 132, 256 
imbecility, 114 
intracranial pressure, 

256 
insanity, 267 
meningitis, 274 
tumors, 200, 265 
methods of, 280 
operation of, 276 
personal cases of, 29-54, 
140-149, 161, 174, 185, 
228-250 
statistics of, see Statistics 
technique of, 276 
Trimble, 137 
Trunk, motor area of, 4 
Tubercular tumors, 202, 204, 205 



INDEX. 



295 



Tumors of the brain, 200 

analysis of operations for, 

216 
analysis of 600 cases, 202 
cases open to operation, 209 
cases operated upon, 220-250 
cerebellar, 238 
cerebral, 217 

conclusions regarding opera- 
tion for, 254 
cortical, 217 
diagnosis of, 204, 306, 212, 

238 
frequency of, 201 
hemorrhages in, 208 
in adults, 201, 212 
in centrum ovale, 212 
in cerebellum, 211, 238 
in cerebral axis, 209 
in cerebral cortex, 212 
in children, 201, 211 
multiple, 204 
per cent of cases operable, 

213, 214 
situation of, 209 
structure of, 208 
symptoms of, 208, 212, 238 
tables of cases of, see Tables 
varieties of, 201 
Twynam, 253 



Uncinate gyrus, 8 

Van Gieson, 72, 78-111 
Varieties of abscess, 180 

aphasia, 6 

epilepsy, 19 

tumor, 201 
Verco, 252 
Visual area of brain, 6, 7 

tract in brain, 9 

Wagner, 271 

Weeks, 241 

Weir, 38, 148, 174, 221, 251, 253, 

273, 275 
Welt, 232 
Wernicke, 258 
White, Hale, 214 
Wilbrand, 122 
Willard, 138 
Wollenhurg, 245 
Wood, 227 
Woolsey, 63 

Wounds of the brain, 76 
Wyeth, 137 
Wyman, 253 

Zenner, 258 
Ziegler, 76 



